Effects of eating breakfast compared with skipping breakfast on ratings

of appetite and intake at subsequent meals in 8- to 10-y-old children13

Tanja VE Kral, Linda M Whiteford, Moonseong Heo, and Myles S Faith

INTRODUCTION

There has been a steady decline in breakfast consumption in

US adults and children over the past 40 y (13). Specifically,
Siega-Riz et al (3) observed that, from 1965 to 1991, breakfast
consumption declined among preschoolers, 8- to 10-y old children, and adolescents by 5%, 9%, and 1320%, respectively. A
recent survey conducted in a nationally representative sample
of 11- to 15-y-old youth indicated that only 54% of boys and 42%
of girls ate breakfast daily (4). Minority children, and girls in
particular, and children from low-income families show increased breakfast skipping (5, 6). The decline in breakfast
consumption has coincided with an increase in the prevalence of
childhood obesity, suggesting that dietary patterns may be implicated in the overconsumption of calories in young children.

284

Some (4, 711), but not all (12, 13), cross-sectional studies
have shown a positive association between skipping breakfast and
measures of adiposity in children. It has been suggested that
skipping breakfast may lead to overall greater levels of hunger
later in the day, which in turn may lead to overeating foods,
particularly those that are higher in energy density. Data on the
effects of skipping breakfast on childrens appetite and intake
later in the day have been conflicting. Cross-sectional studies that
used self-report measures of dietary intake indicated that children
who regularly consumed breakfast showed higher daily energy
intakes than did children who regularly skipped breakfast (1416).
There have been few laboratory studies that have experimentally tested the effects of breakfast on subsequent intake.
There is some evidence that the macronutrient content or glycemic
index of breakfast may affect satiety and intake at subsequent
meals among youth. For example, a study in breakfast-skipping
adolescents showed reduced energy intake at lunch after a protein-rich breakfast compared with no breakfast or a normal-protein
breakfast (17). Another study by Warren et al (18) indicated that
energy intake at lunch was significantly reduced among 9- to
12-y-old children after they consumed a lowglycemic index
breakfast compared with a highglycemic index breakfast. To our
knowledge, no study to date has tested the effects of consuming
breakfast compared with skipping breakfast on subsequent energy intake in a younger age group.
The primary aim of this study was to test the effects of
consuming breakfast compared with omitting breakfast on energy
intake, percentage of calories from fat, and dietary energy density
at subsequent meals in children aged between 8 and 10 y. A
secondary aim was to examine childrens ratings of appetite
throughout the morning after consuming or omitting breakfast. It
was hypothesized that on the day when children did not consume
1

From the Department of Psychiatry, School of Medicine, University of

Pennsylvania, Philadelphia, PA (TVEK, LMW, and MSF), and the Department of Epidemiology and Population Health, Albert Einstein College of
Medicine, Bronx, NY (MH).
2
Supported by the General Mills Bell Institute of Health and Nutrition,
Minneapolis, MN. TVEK is supported by National Institutes of Health grant
K01DK078601. General Mills provided all ready-to-eat breakfast cereals as
well as $10 gift cards for child participants.
3
Address correspondence to TVE Kral, Center for Weight and Eating Disorders, University of Pennsylvania School of Medicine, 3535 Market Street,
Suite 3031, Philadelphia, PA 19104. E-mail: tkral@mail.med.upenn.edu.
Received July 26, 2010. Accepted for publication November 4, 2010.
First published online November 17, 2010; doi: 10.3945/ajcn.110.000505.

Am J Clin Nutr 2011;93:28491. Printed in USA. 2011 American Society for Nutrition

Downloaded from ajcn.nutrition.org by guest on June 8, 2016

ABSTRACT
Background: Cross-sectional data indicate an inverse relation between breakfast consumption and child weight. It has been suggested that skipping breakfast may adversely affect appetite in
children, which could lead to overeating later in the day.
Objective: The aim of this study was to test the effects of consuming breakfast compared with omitting breakfast on appetite ratings
and energy intake at subsequent meals in 8- to 10-y-old children.
Design: Twenty-one children participated in 2 test visits during
which they were served either a compulsory breakfast or no breakfast. On both visits, subjects were also served lunch, which was
consumed ad libitum. Subjects rated their appetite throughout the
morning; parents completed food records that captured childrens
intake for the remainder of the day.
Results: There was no significant main effect of breakfast condition
on energy intake at lunch (P = 0.36) or throughout the remainder of
the day (P = 0.85). There was a significant main effect of breakfast
condition (P = 0.04) on total daily energy intake, which indicated
that on the day when the subjects did not eat breakfast, they consumed 362 fewer calories over the course of the day than when they
did eat breakfast. On the day when no breakfast was served, subjects
indicated that they were significantly hungrier, less full, and could
consume more food before lunch than on the day when they did eat
breakfast (P , 0.001).
Conclusions: Omitting breakfast affected childrens appetite ratings
but not their energy intake at subsequent meals. The dissonance
between childrens subjective ratings of prospective consumption
and their actual intake should be further examined.
Am J Clin
Nutr 2011;93:28491.

BREAKFAST CONSUMPTION AND SATIETY

285

breakfast, they would be significantly hungrier and would consume more energy at subsequent meals than on the day when they
ate breakfast.

tile) or overweight (BMI-for-age between the 85th and 94th

percentile) by using the Centers for Disease Control and Prevention growth reference standards (19).

SUBJECTS AND METHODS

Assessment of taste preference

Experimental design
The study used a crossover design with repeated measures
within participants. Children attended 2 test visits at the Center
for Weight and Eating Disorders (CWED) at the University of
Pennsylvania. Test visits were scheduled 1 wk apart and occurred
on the same day of the week. On each test day, the same foods
were served for lunch, but children either consumed or did not
consume breakfast. On the day when breakfast was served,
children were asked to consume the breakfast in full. During
lunch, children could eat and drink as much or as little as they
desired. The order of presenting the breakfast conditions was
randomly assigned across participants.

Participants in this study were 15 girls and 6 boys living in the

greater metropolitan area of Philadelphia. Families of all racial
and ethnic backgrounds were recruited through online and
newspaper advertisements and local flyers. To be included in the
study, children were required to be between 8 and 10 y of age,
have a body mass index (BMI)-for-age between the 5th and 94th
percentile, and like most foods that were served in the study (see
section entitled Assessment of taste preference). Children
were excluded from participation in this study if they had serious medical conditions known to affect food intake and body
weight; any learning disability or visual or auditory impairment;
any developmental, medical, or psychiatric conditions that
might affect study compliance; any food allergies; or were
taking medications known to affect food intake or body weight.

Assessment of dietary intake

The amount and energy content of each food and beverage
item served at breakfast and lunch are shown in Table 1. All
foods and beverages that were provided during breakfast and
lunch were weighed before being served to children and reweighed after children finished eating to determine the amount
consumed by each child to the nearest 0.1g.

Recruitment and screening

Breakfast

Interested families were screened by phone to determine

whether their children met the initial inclusion criteria for the
study. Families who prequalified for the study from the telephone
interview were invited to attend an onsite screening visit at
CWED. During the screening visit, parents and their children
received a detailed explanation of all study procedures and were
asked to provide voluntary assent (child) and consent (parent) to
participate in this study by signing the consent and assent forms.
The study was approved by the Institutional Review Board of the
University of Pennsylvania.

Breakfast consisted of ready-to-eat breakfast cereal (General

Mills Cereals, Minneapolis, MN), milk (1% fat; WAWA, Wawa,
PA), banana, and orange juice (Tropicana Products, Chicago, IL).
The breakfast containing cereal A provided 12.4 g protein, 68.9 g
carbohydrate, 3.8 g fat, 3.9 g fiber, and 43.5 g sugar. The breakfast
containing cereal B provided 9.9 g protein, 68.0 g carbohydrate,
5.1 g fat, 2.6 g fiber, and 42.9 g sugar. The breakfast containing
cereal C provided 11.3 g protein, 69.1 g carbohydrate, 3.3 g fat,
2.8 g fiber, and 45.9 g sugar. Calories provided during breakfast
(350 kcal) comprised 19% of childrens daily estimated energy
requirement. The size of the breakfast was determined on the
basis of intakes from previous studies with a similar age group
(14, 22).

Assessment of height and weight

At the onsite screening visit, childrens height and weight were
measured by trained staff members. Childrens weight was
measured on a digital scale (Tanita model BWB-800; Tanita
Corporation of America Inc, Arlington Heights, IL; accurate to
0.1 kg). Standing height was measured on a wall-mounted stadiometer (accurate to 0.1 cm). All measurements were made with
child participants wearing light clothing and without shoes. BMI
percentiles and z scores were calculated for children with ageand sex-specific reference data (19). Children were classified as
normal weight (BMI-for-age between the 5th and 84th percen-

Lunch
Lunch consisted of pasta (New World Pasta, Harrisburg, PA),
tomato sauce (Campbell Soup Company, Camden, NJ), broccoli
(Hanover Foods Corporation, Hanover, PA), applesauce (Motts,
Rye Brook, NY), chocolate chip cookies (Kraft Foods, East
Hanover, NJ), and milk (1% fat; WAWA). The amounts of foods
served were determined on the basis of intake data (per eating
occasion) from the Continuing Survey of Food Intakes by

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Participants

At the onsite screening visit, childrens preference for all foods

and beverages served during the study was assessed by using
a validated taste preference assessment procedure (20, 21).
During the preference assessment, each child tasted a small
amount (23 spoonfuls) of each of 3 types of ready-to-eat
breakfast cereals and selected lunch foods (pasta with tomato
sauce, broccoli, and applesauce). Children rated their preference
for milk, orange juice, banana, and chocolate chip cookies
without tasting them. Children rated each food by using 3 cartoons depicting a smiling face (yummy), a neutral face (just
okay), or a frowning face (yucky). Only children who rated
the majority of the foods with a smiling or neutral face were
invited to participate in the study. Once children finished rating
all foods, a rank-order preference assessment was performed for
the ready-to-eat breakfast cereals only. During this rank-order
assessment, children were asked to indicate the most yummy
ready-to-eat breakfast cereal, the second most yummy readyto-eat breakfast cereal, and so forth. In an effort to counterbalance cereal types (an equal number of children received each
cereal type), subjects received either their favorite or second
favorite cereal (as determined by subjects ranking score).

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KRAL ET AL

TABLE 1
Foods and beverages served to 21 children during breakfast and lunch1
Amount
served

Volume

Energy
content

kcal/g

cups

kcal

3.9
4.2
4.1
0.4
0.9
0.4

33
31
32
192
60
187

0.75
0.75
0.75
0.75
0.40
0.75

130
130
130
85
53
82
350

1.3
0.3
0.4

700
140
240

3.5
1
1

903
41
98

4.8

30

144

0.4

244

108
1294

Children were required to eat the breakfast in full; lunch was consumed ad libitum.
2
General Mills Cereals, Minneapolis, MN.
3
WAWA, Wawa, PA.
4
Tropicana Products, Chicago, IL.
5
New World Pasta, Harrisburg, PA, and Campbell Soup Company,
Camden, NJ.
6
Hanover Foods Corporation, Hanover, PA.
7
Motts, Rye Brook, NY.
8
Kraft Foods, East Hanover, NJ.

Individuals (23) for children aged 611 y. The size of the pasta
entree exceeded the 95th percentile of intake; the size of broccoli
and applesauce fell between the 75th and 95th percentile of
intake; the size of chocolate chip cookies and milk corresponded
to the 50th percentile of intake for children in that age group. The
meal provided more energy (1294 kcal) than most children were
likely to consume. Portion sizes remained constant across experimental conditions.
Intake for the remainder of the day
At the end of each test visit, parents were instructed to complete
a food record, which captured their childrens food and beverage
intake throughout the remainder of the day (away from the laboratory). Parents received detailed training on how to correctly
complete the food records. The food record training was conducted
by a trained clinical research coordinator. With the use of written
instructions (ie, handout that was provided to the parents), parents
were trained on the details (ie, time, type, preparation method, and
amounts of foods and beverages consumed) of accurately completing the food records. The written instructions also included
visual aids for portion size estimates. In addition, parents were
provided with a sample of a correctly completed food record.
Parental assistancewith completion offood records has been shown
to significantly enhance the accuracy of self-reported dietary intake
in children (24). Food records were entered by trained staff
members and analyzed by using the Food Processor SQL software
(ESHA), version 9.8 (2005; ESHA Research, Salem, OR).

Subjects were asked to rate their perceived hunger, thirst,

prospective consumption (how much food they thought they
could eat), nausea, and fullness by using a 100-mm visual analog
scale (VAS) with opposing anchors (eg, extremely hungry or
not at all hungry). VASs have been successfully used in
children and adolescents to assess perceptions of appetite (25, 26)
and pain (27, 28). VAS ratings were completed at the following 7
time points throughout each test visit: 0815 (on arrival to the
laboratory); 0915 (immediately after breakfast on the day
breakfast was served); 0930, 1015, 1100, and 1140 (immediately
before lunch); and 1205 (immediately after lunch).
Procedures
On the day of their test visit, parents/caretakers were instructed
to have their child refrain from eating and drinking (except for
water) from the time they got up in the morning until the start of
their test visit. For each visit, children came to the laboratory
individually. On arrival at the center at 0800, parents/caretakers
were asked to complete a meal/snack report to ensure that they
had complied with the study procedures. Subjects were either
served or not served breakfast on the morning of their test visit.
On the day when breakfast was served, children were asked to
consume the breakfast in full over a period of 30 min. Subjects
completed VASs at regular intervals throughout the morning (see
the section entitled Appetite ratings). Subjects also completed
a series of 8 computerized cognitive tasks at 4 different time
points throughout the morning (data not shown). During times
when no formal activities were scheduled, subjects rested while
listening to audio CDs or playing games. Subjects were allowed
to drink water throughout the morning, if desired. On both test
visits, subjects were served lunch at 1145. During the meal,
subjects could eat or drink as much or as little as they desired
over a period of 20 min. Subjects consumed breakfast and lunch
in the presence of a research assistant who waited in an adjacent
room. Parents/caregivers waited at the center or in close proximity for the duration of the study visit.
Statistical analysis
Subject characteristics are described by means and SDs for
continuous variables and by percentages for categorical variables.
Both study aims were tested by using mixed-effects linear models
for repeated measures (SAS version 9.2 for Windows; SAS Institute Inc, Cary, NC). We first tested for potential carryover
effects by testing for significance of a possible order effect of
breakfast condition. This was to ensure that the results were not
confounded by the order of the breakfast manipulation. There
were no significant carryover effects in any primary or secondary
outcomes in either aim.
For aim 1, the primary outcome was energy intake at lunch.
Secondary outcomes were energy consumed throughout the remainder of the day, total daily energy intake (sum of calories
consumed at breakfast, lunch, and during the remainder of the
day), percentage of energy consumed from fat, and dietary energy
density. Energy density of the food consumed at lunch (laboratory
meal) and throughout the remainder of the day (self-reported
intake), excluding beverages, was computed by dividing the
total energy consumed from food by the total weight of food

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Breakfast
Choice of 3 cereals2
Cereal A
Cereal B
Cereal C
Milk, 1% fat3
Banana
Orange juice4
Total energy
Lunch
Rotini with tomato sauce5
Broccoli6
Applesauce
(unsweetened)7
Chocolate chip
cookies (3)8
Milk, 1% fat3
Total energy

Energy
density

Appetite ratings

BREAKFAST CONSUMPTION AND SATIETY

RESULTS

Subject characteristics
Anthropometric and demographic characteristics of child
participants are shown in Table 2. The majority of the sample
was female (71.4%) and African American (76.2%). ApproxiTABLE 2
Anthropometric and demographic characteristics of child participants
(n = 21)
Characteristic
Age (y)
Sex [n (%)]
Male
Female
Race [n (%)]
African American
White
Mixed race
BMI (kg/m2)
BMI z score
BMI-for-age percentile
Weight status [n (%)]
Normal weight
Overweight
1

Mean 6 SD (all such values).

Values
9.2 6 0.81
6 (28.6)
15 (71.4)
16 (76.2)
4 (19.0)
1 (4.8)
17.4 6 2.5
0.25 6 0.9
57.3 6 29.4
15 (71.4)
6 (28.6)

mately one-third of the sample (28.6%) was considered overweight. Child participants daily breakfast consumption patterns
are shown in Table 3. The majority of the children consumed
breakfast on a daily basis both during weekdays (90.5%) and on
weekends (95.2%). Approximately half of the sample (52.4%)
consumed cereal for breakfast 3 d/wk.

Preference ratings for experimental foods and beverages

The proportion of children who rated the breakfast foods
acceptable (yummy or just okay) was 95% for cereal A,
100% for cereal B, 86% for cereal C, 100% for banana, and 100%
for orange juice. The proportion of children who rated the lunch
foods acceptable was 100% for pasta, 76% for broccoli, 95% for
applesauce, 95% for chocolate chip cookies, and 76% for milk.

Effects of breakfast on intake

As indicated in Table 4, there was no significant main effect
of breakfast condition (P = 0.36) or test week (P = 0.84) on the
amount of calories children consumed at lunch. Hence, subjects
showed similar energy intakes at lunch after consuming breakfast (634 6 50 kcal) compared with after skipping breakfast
(593 6 50 kcal). The results did not change when excluding the
one subject who finished all of the pasta from the analyses (main
effect of breakfast condition: P = 0.32).
There was also no significant main effect of breakfast condition (P = 0.85) on the amount of calories children consumed
for the remainder of the day [1207 6 134 kcal (breakfast)
compared with 1237 6 134 kcal (no breakfast)]. There was
a trend (P = 0.08) for energy intake for the remainder of the day
to be higher during the first test week (1364 6 134 kcal) than
during the second test week (1080 6 134 kcal).
There was a significant main effect of breakfast condition (P =
0.04) on total daily energy intake. On the day when subjects ate
breakfast, they consumed 362 more calories over the course of
the day and thereby exceeded their daily EER by 20% compared with the day when they did not eat breakfast (Figure 1).

TABLE 3
Breakfast habits of child participants (n = 21)
Characteristic

Frequency
n (%)

Children who eat breakfast

3 d/wk
4 d/wk
5 d/wk
Children who eat breakfast
1 d/weekend
2 d/weekend
Children who eat cereal for breakfast
Never
1 d/wk
2 d/wk
3 d/wk
4 d/wk
5 d/wk
6 d/wk
7 d/wk

1 (4.8)
1 (4.8)
19 (90.5)
1 (4.8)
20 (95.2)
1 (4.8)
0
1 (4.8)
11 (52.4)
4 (19.0)
2 (9.5)
0
2 (9.5)

Downloaded from ajcn.nutrition.org by guest on June 8, 2016

consumed. The fixed effects used in all models were breakfast

condition (breakfast or no breakfast) and test week; subject-level
intercepts were considered as being random. The interaction
between breakfast condition and session (week) was tested for
significance in all models and removed if not significant. The
influence of childrens sex and BMI z score on all outcome
measures was also examined by adding these variables as a covariate to the model. We identified one child who consumed the
entire main entree (defined as eating .95% of the amount
served) in one experimental condition. The analysis of the main
outcome (energy intake at lunch) was conducted both including
and excluding the child who consumed the entire entree to investigate whether a limitation of main entree availability influenced the main outcome. The computation of subjects daily
estimated energy requirement (EER) was based on age-, sex-,
and weight-, and height-specific equations (29). Due to the lack
of an objective, validated measure to assess subjects physical
activity level, we assigned all subjects to the low active
physical activity category, which corresponds to a physical activity coefficient of 1.13 for boys and 1.16 for girls and assumes
typical daily living activities plus 3060 min of daily moderate
activity (30, 31).
For aim 2, for each VAS (ie, hunger, thirst, nausea, prospective
consumption, and fullness) the full mixed-effects model included
breakfast condition, time, session, baseline VAS, and breakfast
condition-by-time interaction as fixed effects and both the thirdlevel (subject-level) and second-level (treatment-level nested
within subjects) intercepts as random effects. Subjects baseline
VAS (ie, obtained at 0815) was included as a covariate in the
model. Data are presented as model-based means 6 SEMs unless
otherwise indicated. For all analyses, results were considered
significant at P , 0.05.

287

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KRAL ET AL
TABLE 4
Energy intake, percentage of energy from fat, and energy density (food only) consumed at lunch and throughout the
remainder of the day by breakfast condition (n = 21)1

Lunch
Energy intake (kcal)
Percentage of energy from fat (%)
Energy density (kcal/g)
Remainder of day
Energy intake (kcal)
Percentage of energy from fat (%)
Energy density (kcal/g)
1

No breakfast

Breakfast

P value

593 6 50
15.3 6 1.0
1.25 6 0.06

634 6 50
15.0 6 1.0
1.25 6 0.06

0.36
0.80
0.91

1237 6 134
32.9 6 2.3
2.08 6 0.16

1207 6 134
29.9 6 2.3
2.16 6 0.16

0.85
0.34
0.68

All values are means 6 SEs. Data were analyzed by using mixed-effects linear models with repeated measures.

Ratings of appetite
Model-based means for child ratings of hunger, thirst, prospective consumption, and fullness throughout the morning are
shown in Figure 2. There was a significant breakfast conditionby-time interaction (P , 0.001) on ratings of hunger, indicating
that on the day when children did not consume breakfast they
felt significantly hungrier throughout the morning (0915, 0930,

FIGURE 1. Mean (6SE) calories consumed from breakfast (white

portion of the bar), lunch (gray portion of the bars), and throughout the
remainder of the day (black portion of the bars) by breakfast condition
(n = 21). Total daily energy intake significantly differed between breakfast
conditions (P = 0.04) based on a mixed linear model with repeated measures.
*Significant difference in total energy intake between experimental conditions
(P ,0.05).

1015, 1100, and 1140) than when they did consume breakfast.
There was also a borderline significant breakfast condition-bytime interaction (P = 0.05) on ratings of thirst, indicating that on
the day when children did not eat breakfast, they were significantly thirstier at 0915 (P = 0.002) than on the day when they
did consume breakfast. Furthermore, there was a significant
breakfast condition-by-time interaction (P , 0.001) on childrens ratings of prospective consumption, indicating that on the
day when children did not eat breakfast, they indicated that they
could eat significantly more food before lunch (0915, 0930,
1015, 1100, and 1140; P , 0.001) than on the day when they
were served breakfast. There also was a significant breakfast
condition-by-time interaction (P , 0.001) on ratings of fullness,
indicating that on the day when children were not fed breakfast
they felt significantly less full throughout the morning (0915,
0930, 1015, and 1100; P , 0.001) than on the day when they ate
breakfast. There was no significant main effect (P = 0.39) of
breakfast condition or breakfast condition-by-time interaction
(P = 0.07) on childrens level of nausea.

DISCUSSION

This study showed that when children, the majority of whom

were regular breakfast eaters, did not eat breakfast on a single
day, they did not make up for the missing calories from breakfast
by eating more calories at lunch or throughout the remainder of
the day. The dietary energy density and percentage of energy
consumed from fat at subsequent meals also did not differ across
experimental conditions. On the day when no breakfast was
served, children indicated that they were significantly hungrier,
less full, and could consume more food before lunch than on the
day when they did eat breakfast.
In this study, skipping breakfast affected childrens appetite
ratings but not their energy intake at subsequent meals. Therefore, on the day when children did eat breakfast, they consumed
362 more calories than on the day when they skipped breakfast.
This finding corroborates results from studies based on selfreported intake that showed a higher daily energy intake among
children who regularly consumed breakfast compared with those
who regularly skipped breakfast (1416). In the current study, on
the day when child participants consumed breakfast, they
exceeded their daily EER by 20%. Although interesting, this
finding should be interpreted with caution by taking into account
the estimated, rather than observed, energy intake throughout
the remainder of the day as well as childrens estimated physical

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None of the results changed when the model was adjusted for
childrens sex or BMI z score.
There was also no significant main effect of breakfast condition or test week on percentage of energy consumed from fat at
lunch (breakfast condition: P = 0.80; test week: P = 0.12) or
throughout the remainder of the day (breakfast condition: P =
0.34; test week: P = 0.90; Table 4). There was no significant
main effect of breakfast condition or test week on the overall
energy density of foods that children consumed at lunch
(breakfast condition: P = 0.91; test week: P = 0.65) or
throughout the remainder of the day (breakfast condition: P =
0.68; test week: P = 0.36).

BREAKFAST CONSUMPTION AND SATIETY

289

activity level to compute their daily EER. Furthermore, with

76% of mothers in the current study classified as either overweight or obese (data not shown), the majority of the children,
despite being of normal weight, were predisposed to obesity.
Parental obesity, and maternal obesity in particular, is a significant predictor of obesity in the offspring (32). It is possible that
the widespread familial predisposition to obesity in this cohort
of children may in part help explain childrens high daily energy
intake. More studies are needed that experimentally test the
effects of eating compared with skipping breakfast on measured
intake over multiple meals to more accurately investigate
childrens longer-term energy intake regulation.
The current study used a fairly homogenous sample with
respect to childrens habitual breakfast habits and weight status.
The majority of children in the current study were regular
breakfast eaters. It is possible that children who regularly skip
breakfast may show different energy intake patterns throughout
the day compared with children who regularly eat breakfast and
who may skip breakfast only occasionally. In other words, the
long-term effects of skipping breakfast on energy intake may
develop over time and may involve learning of new eating
patterns. Furthermore, the current study was limited to normalweight and some overweight child participants. It is possible that
obese children (ie, those with a BMI-for-age 95th percentile)
may have responded differently in that they may have consumed
more calories later in the day after skipping breakfast compared
with predominantly normal-weight children. Data from a prospective cohort study with 9- to 14-y-old children showed that

overweight children who never ate breakfast lost weight over

a 1-y period compared with overweight children who consumed
breakfast nearly every day (33). In contrast, there was a trend for
normal-weight children who never ate breakfast to gain weight
compared with their normal-weight peers who ate breakfast
nearly every day. These findings suggest that skipping breakfast
may affect children differently and may depend on child characteristics, such as their weight status.
With respect to ratings of appetite, children indicated that they
were significantly hungrier and less full on the day when they did
not consume breakfast. This finding confirms our initial hypothesis and suggests that children, the majority of whom in our
study were habitual breakfast eaters, do show changes in their
hunger and fullness when deprived of breakfast. On the day when
children did not eat breakfast, children indicated that they could
eat significantly more food before lunch compared with when
they did consume breakfast. Given that there were no significant
differences in energy intake at lunch between experimental
conditions, this finding is interesting. It suggests that there was
a dissonance between childrens subjective ratings of how much
they thought they could eat and their actual intake at lunch.
Whereas VAS ratings have shown sensitivity to experimental
conditions, subjectively expressed hunger or appetite is not
necessarily predictive of actual food intake (34). It is possible that
the standardization of the lunch meal (same types and amounts of
foods served across experimental conditions) or other laboratory
factors may have contributed to similar intakes between conditions despite differences in appetite ratings. More studies are

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FIGURE 2. Mean (6SE) ratings of appetite using visual analog scales by breakfast condition (n = 21). Data were analyzed by using a mixed-effects linear
model with repeated measures. There was a significant breakfast condition-by-time interaction for ratings of hunger (P , 0.001), thirst (P = 0.05), prospective
consumption (P , 0.001), and fullness (P , 0.001). Gray dotted lines indicate no-breakfast condition; black solid lines indicate breakfast condition.
*Significant difference between experimental conditions (P , 0.05).

290

KRAL ET AL

We acknowledge the contributions of the students at the Center for Weight

and Eating Disorders at the University of Pennsylvania who assisted with this
study.
The authors responsibilities were as followsTVEK and MSF: study design, interpretation of the data, and critical revision of the manuscript; LMW:
data collection; MH and TVEK: statistical analysis; and TVEK: writing of the
manuscript. None of the authors had a conflict of interest. The sponsor (General Mills Bell Institute of Health and Nutrition, Minneapolis, MN) had input
into the study design but did not participate in the implementation of the study,
statistical analyses, or interpretation of the results.

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needed that systematically study the effects of meal patterns and

food components on satiety in children.
Due to the greater risk of obesity and obesity-related diseases
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design to assess multiple meals that include a wider range of
foods and beverages. It is also important in future studies to test
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lunch. Last, our ability to detect significant findings was constrained by our sample size, despite our use of a within-subjects
design. The effect size for measured energy intake at lunch was
small (Cohens d = 0.20). A post hoc power analysis indicated
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results for measured energy intake at lunch at 80% statistical
power. Future studies addressing this topic might require larger
samples, depending on the particular hypothesis and measures
that are used.
In conclusion, the findings from this study showed that despite
differences in subjective feelings of hunger and appetite, children
who regularly consume breakfast did not compensate or overcompensate for the missing calories from a skipped breakfast on
a single occasion by eating more later in the day.

BREAKFAST CONSUMPTION AND SATIETY

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