ABSTRACT
Breakfast skipping and late-evening snack are prevalent in young adults. This randomized controlled intervention aimed to evaluate the influence of meal habit recommendations on young adults’ body composition and blood pressure. Nonpregnant adults (≥20 y old) who were eligible for bioelectrical impedance analysis examination (neither pacemaker installed nor medications that would affect body composition, like diuretics or corticosteroids) were enrolled after they provided informed consent (n = 125). Subjects were randomized into three groups, every group receiving one of the following recommendations: (a) daily breakfast consumption (within 2 h after waking up), (b) avoidance of late-evening snacks (after 21:00h or within 4 h before sleep, with the exception of water), and (c) both recommendations. Body composition and blood pressure were measured before randomization at baseline and at the follow-up 1 y later. Intent-to-treat analysis showed that the recommendation of daily breakfast may contribute to a lower increment of diastolic blood pressure by 3.23 mmHg (95% CI: 0.17–6.28). Receiving the breakfast recommendation was associated with more reduction of total body fat percent by 2.99% (95% CI: 0.23–5.74) and percent trunk fat by 3.63% (95% CI: 0.40–6.86) in inactive youths. Recommendation of avoiding late-evening snack did not significantly affect the outcome measures (ClinicalTrials.gov Identifier: NCT03828812).
Introduction
Eating behaviors such as breakfast skipping and late-evening eating have become increasingly common (Almoosawi et al. Citation2016; Kant and Graubard Citation2015a). Misalignment between circadian rhythm and eating time during the day has been associated with interfered metabolisms (Pickel and Sung Citation2020). Breakfast is an environmental cue that helps entrain the peripheral circadian rhythm of nutritional metabolism to the central nerve system (Asher and Sassone-Corsi Citation2015; Oike et al. Citation2014). Epidemiological studies have linked late breakfast and breakfast skipping with an increased risk of metabolic syndrome, diabetes, and cardiovascular diseases (Cahill et al. Citation2013; Chen et al. Citation2020; Mekary et al. Citation2013; Palomar-Cros et al. Citation2023). As for late-evening eating, observational studies consistently associated late-evening eating with higher energy intake (Sebastian et al. Citation2022), overweight/obesity (Bo et al. Citation2014; Longo-Silva et al. Citation2022; Yoshida et al. Citation2018), elevated blood glucose, lipids (Chen et al. Citation2019; Yoshida et al. Citation2018), and blood pressure (Almoosawi et al. Citation2013; Chen and Pan Citation2017; Chen et al. Citation2021; Kakamu et al. Citation2019).
Despite the growing evidence from observational studies, results from randomized trials were inconsistent. Randomized interventions specifically on the effect of breakfast recommendation have been small and short-term, lasting from days to 16 weeks. For example, the Bath Breakfast Project randomized the participants to breakfast eaters (recommended to eat breakfast daily before 11:00h) and breakfast skippers (recommended to keep zero energy intake in the morning until 12:00h) for 6 weeks in a free-living setting but found no significant differences in metabolic changes or adiposity between the intervention and control groups (Betts et al. Citation2014; Chowdhury et al. Citation2016). Another larger randomized controlled intervention in the US (with 309 participants for 4 months) compared breakfast group (recommended to consume breakfast before 10:00h) to a no breakfast group (recommended to have zero energy intake before 11:00h) and a control group (provided with general nutrition recommendations) but did not find significant difference in weight loss between the groups (Dhurandhar et al. Citation2014). Meta-analysis studies of the breakfast trials yielded equivocal results regarding whether breakfast promotion could affect body weight and metabolic health (Bonnet et al. Citation2020; Sievert et al. Citation2019). A randomized trial has attributed better weight management outcome to an earlier evening eating (Madjd et al. Citation2021). There were also some contrary findings from a crossover trial that evening snack would have lower variation of postprandial glucose level compared to morning snack (Timmer et al. Citation2022). However, unlike breakfast promotion, there is currently no evidence showing the impact of recommending the avoidance of late-evening snacking on health outcomes.
Prevalence of breakfast skipping and late-evening eating among college students and young adults is high (Chau et al. Citation2017; Kito et al. Citation2019; Pendergast et al. Citation2016). Since it is still uncertain whether recommendations of eating breakfast and avoiding late-evening snack would affect health outcomes, the randomized trial aimed to investigate the 1-y impact of two different recommendations on body composition and blood pressure. Specifically, this study examined the effects of suggesting daily breakfast and avoiding late-evening snacks separately, given the other recommendation is present.
Methods
Subjects
Participants were recruited on campus of National Yang-Ming University, Taipei from August 2016 to July 2017. The subjects were recruited from online advertisement on students’ Facebook club pages and printed flyers posted on campus. Nonpregnant adults (≥20 y old) with good daily physical and cognitive function to answer the questionnaire, and those who were eligible for bioelectrical impedance analysis (BIA) examination (persons without pacemaker installed and without medications that would affect body composition like diuretics or corticosteroids) were eligible to be enrolled. The study was conducted according to the guidelines in the Declaration of Helsinki and passed review by Internal Review Board of the National Yang-Ming University (project no: YM104136E) and registered (ClinicalTrials.gov Identifier: NCT03828812). Written informed consent was obtained from all subjects.
At the time of study design, sample size calculation was based on the results of a 12-week breakfast intervention where body fat% was 38.1 ± 1.6 and 39.5 ± 1.1 at the end of trial respectively for breakfast and control group (Schlundt et al. Citation1992). To reach alpha value 0.05 and 90% statistical power, 27 subjects were required for each arm. Considering the high attrition rate of non-pharmacological weight intervention (34.5%) (Fabricatore et al. Citation2009), the sample size for each arm was finalized at 42, i.e. 126 in total. By the end of the funding period of the baseline project, 125 subjects completed informed consent, baseline interview, and intervention assignment.
Intervention
This was a three-arm open-label parallel randomized trial. The participants were randomized into three meal habit recommendation groups (1:1:1). Random numbers were generated on MS Excel with a block size of 3. One of the authors (HJC) generated randomized sequence of assignment, while YCT, YTH, and JC enrolled participants and assigned participants to interventions. The intervention was meal recommendation, delivered at the end of baseline interview. One-third participants received recommendation of eating breakfast daily (“to have a meal within 2 h after waking up every day”), another one-third participants received recommendation of avoiding late-evening snack (“not to eat/drink after 21:00h, or 4 h before sleep, except for drinking water”), and the rest one-third participants received both recommendations. The “pure” control group without either recommendation was not designed in this study to prevent 1) drop-in issues among participants who had neither recommendations and 2) ethical issues of having neither hypothesized beneficial meal recommendations. The content of intervention was sealed in an envelope until the end of the baseline interview was completed, so that the interviewer and participant were unaware of their intervention before assignment.
Follow-up and adherence
The participants were followed up 1 y (±2 weeks) after the baseline. The 1-y duration was designed to minimize the seasonal changes in body composition, blood pressure, physical activity, and diets. To increase adherence to intervention allocation, the participants were asked to join a Facebook club, where the research team kept posting up-to-date evidence of health values of regular breakfast eating and the up-to-date evidence of health impacts of late-evening eating. The breakfast group received the breakfast-related posts only, the late-evening snack group received the late-evening eating-related posts, and the other group received both types of posts. The Facebook posts aimed to provide reminding cues of the intervention assignment. In the follow-up interview, we measured the participants’ body composition, blood pressure measurements, and dietary habits.
Measures
The primary outcomes of the study were body composition parameters. Participant’s body weight and height were measured directly at baseline and at the follow-up. Body mass index was computed based on the measured weight and height. BIA was used to assess body compositions. TANITA BC-418 8-polar Body Composition Analyzer was used for body composition measurement.
The secondary outcomes of the study were blood pressure parameters. Electronic blood pressure monitor (Microlife®) was used to measure participants’ blood pressure at baseline and follow-up interviews. Participants were asked to sit and rest for 5 min before measurement. The interviewer located the pulse at the antecubital fossa and then applied the artery mark on the cuff to the antecubital fossa. The cuff was placed at the same level as the participant’s heart. Participants took three measurements consecutively. Systolic and diastolic blood pressures and pulse were recorded.
If the first two consecutive readings differed <10 mmHg or beats per minute (bpm), the average of the two readings were taken; if ≥10 mmHg or bpm, the average of all three readings were used.
Usual physical activity was measured on the Mandarin version of International Physical Activity Questionnaire (IPAQ), which was a validated questionnaire to measure individual’s usual physical activity (Liou et al. Citation2008). The IPAQ assessed the usual physical activity in the past week of the interview. Morningness-Eveningness Questionnaire translated in Chinese was used to determine the participant’s chronotype (Horne and Ostberg Citation1976; Zhang and Wing Citation2006).
Participants reported their weekly frequency of breakfast and late-evening snack in the previous month of the baseline and follow-up interview. The participants were also asked to report the perceived fullness of average breakfast on a scale from 0 to 10 (10 means extremely full). In addition, if the participant reported any consumption of breakfast or late-evening snack, they further reported all the clock hours that they usually consumed the meal/snack in the previous month. The earliest and latest clock hour of each meal/snack behavior were used to calculate the range, which indicated the regularity of breakfast and late-evening snack timings. Since tobacco smoking affects appetite and body weight and composition, the subject’s tobacco smoking habit was assessed using questions from the Taiwan National Health Interview Survey.
Socioeconomic status
Employment status was collected, as job was an important determinant of time of eating and drinking for adults (Cheng et al. Citation2007). Participants estimated their monthly expenditure on food (in New Taiwan Dollars) and reported if his/her foods in the recent month were majorly prepared himself/herself. Food security questionnaire was translated into Chinese based on the 10-item US Adult Food Security Survey Module (Economic Research Service, USDA Citation2012).
Statistical analysis
The analysis of the effect of meal recommendations was based on the intent-to-treat analysis. The study population was randomized into three groups, A) both to have breakfast daily and avoid late-evening snack, B) to have breakfast daily, and C) to avoid late-evening snack. By comparing group A to group B, it shows the effect of receiving the recommendation to avoid late-evening snack, among those who were recommended to eat breakfast daily. By comparing A to C, it shows the effect of receiving the recommendation to eat breakfast every day, among those who were recommended to avoid late-evening snack.
We compared the primary and secondary outcomes between the three groups, including body mass index, body fat%, fat mass, systolic and diastolic blood pressures at follow-up. Intent-to-treat t-test was firstly applied to examine the overall difference. In addition to the intent-to-treat analysis, adjusted analysis was used to examine the association between the recommendations and changes of outcome controlling for age, sex, baseline chronotype, physical activity level (IPAQ), and duration between baseline and follow-up. Further, the intent-to-treat differences in changes of breakfast and late-evening snack behaviors (weekly frequency and timings) between baseline and follow-up were examined as well. The exploratory analyses of the effects stratified by sex and physical activity levels were done. Statistical package SAS 9.4 was used for the abovementioned analyses.
Results
In this study, 125 adults were enrolled and randomly assigned to one of three intervention groups. presents the baseline characteristics of the groups, including demographic information, economic status, meal habits, and lifestyle. At baseline, there were no significant differences among the groups, except for the morningness-eveningness orientation, which was found less likely to be intermediate chronotype in the breakfast recommendation group compared to the other two groups.
Table 1. The characteristics of the participants at baseline by intervention groups.
At the end of the study, 23 participants were lost to follow-up (). The follow-up rate was 82%. We compared changes in dietary habits among the participants in the three different recommendation groups (). Overall, the breakfast recommendation was associated with lower decrement of breakfast consumption by 0.21 times/week, and the two recommendations were associated with lower decrements of late-evening snack as well, although these were not significant statistically. Statistically significant differences were shown in the group of low physical activity. In general, the two recommendations were associated with lower decrements of breakfast during the follow-up and also associated with more decrements of late-evening snacks, although not significant. Among those who ate late-evening snacks of the low physical activity group, the latest hour of the late-evening snack was significantly shifted earlier by 3.4 h due to the breakfast recommendation. While the range of hour for late-evening snacks was significantly shortened by 1.6 and 1.3 h, respectively associated with late-evening snack recommendation and breakfast recommendation. For the high physical activity group, breakfast recommendation was unexpectedly associated with 1.5 times/week greater increment of late-evening snack frequency, while the range of hour for late-evening snacks was shortened by 2.4 h although statistical non-significance.
Figure 1. Study sample flow chart.
Table 2. Changes in meal habits among the intervention groups.
presents the distribution of body composition and blood pressure of the three intervention groups, with results stratified by sex and baseline physical activity level. Across all intervention groups, parameters of adiposity and body composition did not exhibit statistically significant changes after follow-up. Although the group receiving both recommendations did not have significant change in diastolic blood pressure, diastolic blood pressure significantly increased by 2.87 (95% CI: 0.66–5.08, p = 0.011) or 4.00 (95% CI: 1.88–6.12, p = <0.001) mmHg in the groups receiving recommendation to eat breakfast daily or avoid late-evening snacks, respectively. Pulse had similar patterns of the diastolic blood pressure changes among the intervention groups.
Table 3. Distribution of body composition and blood pressure parameters at baseline and follow-up by recommendations: pooled, sex-, and physical activity level-stratified analysis.
compares the differences in changes between groups. Recommendation of avoiding late-evening snack seemed to have an additional reduction of percent body fat at truck by 1.30% (95% CI: −0.18 to 2.78, p = 0.085). Overall, receiving the breakfast recommendation was associated with more reductions of BMI, body weight, percent body fat, and percent body fat at the trunk but not statistically significant. However, in low physical activity subgroup, the group receiving both recommendations had greater reductions of body fat by 2.99% (95% CI: 0.23–5.74, p = 0.035) and trunk body fat by 3.63% (95% CI: 0.40–6.86, p = 0.029) than the group receiving recommendation of avoid late-evening snack. In other words, the intent-to-treat analyses showed greater reductions of body fat composition was associated with the breakfast recommendation in low physical activity group.
Table 4. Changes (Δ) of body composition and blood pressure parameters and between-group comparisons.
In terms of blood pressure, the intent-to-treat comparison of the whole sample showed that the increment of diastolic blood pressure was lower in the group receiving both recommendations than in the group receiving only the late-evening snack recommendation by 3.23 mmHg (95% CI: 0.17–6.28, p = 0.039). In other words, the lack of the breakfast recommendation would result in a greater increment of diastolic blood pressure. This pattern was also found in women and in the high physical activity group. Regarding to the effect of recommendation of avoiding late-evening snack, it was only significantly associated with lower pulse in men and low physical activity groups after model adjustment. Overall, there was no significant intent-to-treat effect for recommendation of avoiding late-evening snack.
Discussion
This study investigated the impact of meal habit recommendations on changes in body composition and blood pressure in young adults over 1 y, as unhealthy mealtime patterns are prevalent in this population (Chau et al. Citation2017; Kito et al. Citation2019; Lu et al. Citation2020; Pendergast et al. Citation2016). It is the first study to examine this topic in this age group. The recommendations had some influence on meal habits, and the results suggested that the breakfast recommendation may affect diastolic blood pressure. Additionally, the breakfast recommendation was associated with the changes in weight and body composition among physically inactive young adults. Breakfast consumption has been shown to reduce hunger in the morning and prevent overeating in subsequent meals (Kant and Graubard Citation2015b; Levitsky and Pacanowski Citation2013). In addition, diet-induced thermogenesis is also higher in the morning and consequently higher energy expenditure given the same total energy intake of the day (Morris et al. Citation2015; Richter et al. Citation2020). These energy-balance related mechanisms may explain the more pronounced impact of breakfast in the low physical activity group.
However, previous trials of breakfast recommendations did not show significant effect on body weight and composition. The implementation of intervention components in these trials may have contributed to the different findings. The present study utilized a social media platform to promote recommended meal habits, potentially contributing to higher adherence rates among participants. The impacts of breakfast recommendation on participants’ late-evening snack behaviors and anthropometric outcomes were statistically significant only in the low physical activity group. Young adults with lower physical activity have been associated with digital and social media use (Helbach and Stahlmann Citation2021). As the present study formed an social media group to deliver health information regarding the respective recommendation to the participants during follow-up, the low physical activity group may receive more such informational prompts than the other groups. Nevertheless, we did not collect information of digital or social media use of the participants. The breakfast promoting and late-evening snack avoiding recommendations seemed to have significant effect on improving late-evening snack behaviors, especially the reduced irregular timings (range of) of late-evening snack. This behavioral impact was conditioned on the presence of avoiding late-evening snack recommendation. Although the breakfast recommendation seemed to have impact on those who received late-evening snack recommendation, late-evening snack behaviors changed in the undesirable direction occurred only in the group receiving only late-evening snack recommendation. It is unknown whether recommendation of avoiding an undesirable behavior would become a suggestion of the undesirable compensatory behaviors. Future works need to be aware of unexpected behavioral suggestion, especially the intended restricted behaviors.
Despite the lack of trials examining the independent impacts of late-evening eating in literature, some trials have shown the health impact of redistributing energy intake from late-evening to earlier hours of the day (Young et al. Citation2022). Eating more energy at the earlier hours instead of the later hours of the day would lead to better weight reduction outcomes (Jakubowicz et al. Citation2013; Madjd et al. Citation2021), improved postprandial glucose metabolism (Bandin et al. Citation2015), and lower low-density lipoprotein cholesterol (Hibi et al. Citation2013). Eating at the later hours of the day would contribute to a higher total energy intake (Lecheminant et al. Citation2013), lower nocturnal glucose tolerance and fat oxidation (Gu et al. Citation2020; Kelly et al. Citation2020), and thus greater weight accumulation and metabolic impairments.
The present study found that blood pressure increased less in the group receiving both recommendations than the groups receiving either one recommendation. The stress-independent hypothalamic–pituitary–adrenal (HPA) axis over-activity was hypothesized as an mediator between breakfast skipping and blood pressure elevation (Witbracht et al. Citation2015). Although breakfast skipping was associated with risks of hypertension (Mita et al. Citation2020; Witbracht et al. Citation2015), breakfast intervention studies had inconsistent findings (Bonnet et al. Citation2020). The present study suggested that the breakfast recommendation for 1 y might improve blood pressure profile. Nevertheless, as regard to late-evening snack, the present study did not find significant effect on blood pressure. Late-evening eating has been associated with risk of hypertension in different populations (Almoosawi et al. Citation2013; Chen and Pan Citation2017; Chen et al. Citation2021; Kakamu et al. Citation2019). The impact of late-evening eating on circadian misalignment would contribute to dysregulated blood pressure (Chellappa et al. Citation2019; Ni et al. Citation2019), and snacks chosen at night would also contributed to more sodium intake than those eaten in the morning (Khan Citation1983), which may increase the risk of hypertension. Our study, contrarily, found that the late-evening snacking recommendation did not have significant effect on blood pressure outcomes. While late-evening snacks did not encompass all possible eating occasions that could occur in late evening, e.g. late-evening dinner, the recommendation only targeted at avoiding late-evening snack may be not effective.
Although the sample size was not large, this study took a long follow-up of 1 y and used social media to keep participants with a good retention rate. As the intent-to-treat analysis usually underestimate the effect of intervention, the real effect of the recommendations may be greater than the estimates shown in the paper. Nevertheless, several limitations in this study need to be kept in mind before we make conclusions. First, the study population was drawn from a university-based population. Young adults studying or living at the campus may be not representative of all young adults, especially of youths who had been employed full-time outside of university. It is unknown whether the meal recommendations would be effective or not in changing those health outcomes in all youths. Second, the intervention was open-label and was unable to mask. Third, the present study did not have an intervention arm of receiving neither recommendation due to ethical considerations at the stage of study design. Thus, the joint effect of receiving both recommendations on the outcomes was not assessable.
Conclusion
The study demonstrates that promoting breakfast may be useful for maintaining healthy body composition, especially in the less physically active population, and improving blood pressure levels in young adults. Since the youth population tend to skip breakfast and to have night snack, behavioral change interventions should be designed to prevent such unhealthy meal habits. Improving youth’s mealtime patterns by promoting daily breakfast and avoiding late-evening snack, therefore, could be a useful approach to prevent excessive adiposity, especially for less active people. In addition, future research is needed to confirm the interaction between physical activity level and the effect of meal habit recommendations.
Author contribution
HJC conceived the study and secured the funding. HJC and YCT were responsible for designing the protocol. YCT, YTH, and JC conducted data collection, data processing, and parts of data analyses. HJC supervised the data collection and conducted final data analyses and drafted manuscript. All the authors have reviewed and approved the manuscript.
Acknowledgments
We would like to express gratitude to Tsai-Hsuan Tsai and Chia-Yi Liao’s contribution to data collection and all subjects’ participation.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
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