The study shows that migration background, living with a single parent, female gender, having a percentage of body fat at or above the 95th percentile, the consumption of soft drinks and high levels of screen media use are positively correlated with children skipping breakfast. Reaching high levels of physical activity and tertiary family education level are negatively correlated with skipping breakfast. Accordingly, interventions that influence the reported target behaviors as well as those that are tailored to the identified target groups are necessary. Behavioral changes can be addressed in all kinds of interventions at different levels. Differences between boys and girls should be taken into account according to the gender distribution in the respective target group.
First, parents should be informed about the importance of a healthy lifestyle and health-conscious behavior, such as responsible media consumption, sufficient physical activity, little or no soft drink consumption and most of all the importance of a regular breakfast. Furthermore, parents should be supported in their essential function as a role model for their children and demonstrate healthy breakfast habits. Therefore, interventions should synergistically promote children’s health and involve their parents in order to be successful [
32]. At an organizational level, teachers could inform parents about the need for regular and healthy breakfast for children at parents’ evenings because there are positive effects of breakfast frequency and quality for both parents and children [
33].
Some of the identified family-related factors for skipping breakfast are non- or hardly modifiable, like migration background, family education level and single parenthood. Despite these difficult socioeconomic circumstances (e.g. poor housing, living and working conditions, worries, uncertainty) in which parents have to bring up their children, many of them may be aware of the importance of a healthy lifestyle but lack the necessary resources to implement it. The most promising way to reach children from families with these traits runs via settings like schools or kindergarten. The latter should offer regular breakfast at the start of a school or kindergarten day. In this way, all children are reached and skipping breakfast can be avoided. When developing measures for targeted prevention, there should be a special focus on the needs of the target groups identified in this study. Families in difficult socioeconomic circumstances need to be supported and provided with financial assistance for the payment of breakfast and/or other healthy meals at school. Thus, policy makers and intervention developers have to note that there are low-threshold and easily accessible opportunities required for reaching deprived target groups. Not least, policy makers should support healthy eating habits in schools and kindergartens at all times.
Relevance of breakfast in current research
Although the importance of breakfast consumption to young children’s health is generally known, there is an increasing prevalence of children skipping breakfast [
34,
35]. Food behaviors established in childhood are often continued into adulthood [
36]. Therefore, it is necessary to identify the determinants of skipping breakfast. Based on these determinants, interventions for preventing skipping breakfast and promoting healthy dietary behaviors among children can be developed.
The parental role in the development of children’s healthy breakfast behaviors is not questioned [
37]. Pearson et al. report in their review on family correlates of breakfast consumption that parental breakfast intake is associated with the breakfast intake of their children [
38]. Furthermore, they found out that living in two-parent families also has a positive influence on children’s and adolescent’s breakfast consumption [
38]. The research from Wendy & Campbell also shows that children with single parents are more likely to skip breakfast than those with two parents [
39]. These findings confirm the results of the present study that also found evidence for a relation between family structures and skipping breakfast. Therefore, it is important to consider family structures of the children when designing programs to promote healthy breakfast behavior’s.
Associations between parenting and children’s breakfast consumption were found for permission to skip breakfast and parental self-efficacy of skipping breakfast which were negatively associated with children’s breakfast consumption [
40]. Another study by Fugas et al. shows further reasons for skipping breakfast: lack of time, not being hungry in the morning and feeling unwell at the time of having breakfast are identified as explanations for skipping breakfast before going to school [
41]. Similar to our findings that girls are more likely to skip breakfast than their male peers, other studies showed that breakfast consumption was more frequent among boys [
42,
43]. This result could be explained by the likelihood that even young girls care more about their appearance and a slim figure [
44]. A further study found out that adolescent boys and girls are more likely to skip breakfast if they perceived that their mothers often skip lunch [
45]. Equal results are available for girls skipping breakfast with regard to their best friend’s meal skipping behaviors. On the contrary, those who reported exemplary maternal healthy eating behaviors were less likely to skip breakfast [
45]. These findings underline the importance of interventions to address parents, children and their peers simultaneously.
The investigations of Keski-Rahkonen et al. and Utter et al. show an association between skipping breakfast and having a higher BMI [
43,
46]. Research on breakfast intake and abdominal obesity parameters are rare. Alexander et al. report that eating breakfast was associated with lower visceral adiposity in overweight Latino youth, aged 10 to 17 years [
11]. In a survey of Iranian children and adolescents aged 6 to 18 years the percentage of abdominal obesity in breakfast skippers was almost 5 percentage points higher than in non-skippers [
47]. A French study in primary schoolchildren showed that those who regularly eat breakfast had the lowest waist circumferences [
48].
There are many studies showing a positive relationship between skipping breakfast and a low socioeconomic status [
42,
49]. In the present study, children with migration background were more likely to skip breakfast than their counterparts and a tertiary family education level was positively associated with having breakfast.
Children who spend more time in front of screen media and are less physically active are more likely to skip breakfast than their peers. These results are in line with the results of a study by Tin et al. in Hongkong with primary schoolchildren [
49] and the study of Timlin et al. with adolescents [
42]. Only one study found no relation between physical activity and skipping breakfast [
43]. TV viewing during meals and the consumption of sugar sweetened beverages along with skipping breakfast were associated with significantly higher waist circumferences in French primary schoolchildren [
48].
The probability of skipping breakfast increased with age [
1]. The present study could not detect associations between age and skipping breakfast, probably because of the restricted variation in the age of the participating primary schoolchildren.
Last but not least, there should also be a focus on general meal patterns and obesity. Not just skipping breakfast is associated with obesity but a wide range of obesogenic behaviors influences weight status. Berg et al. showed an association between obesity and skipping breakfast, skipping lunch or eating at night. Larger self-reported portion size was also related to obesity. However, the investigation showed no significant relationship with intake of total energy [
50]. Other authors emphasized that large, high energy-dense portions favor obesogenic eating behaviors in children [
51]. Moreover, serving children large entrée portion sizes increases total energy intake but without decreases in intake of other foods. If children can self-select and limit their food intake, energy intake will decrease [
52]. In this context, it seems necessary not only to consider breakfast skipping children when providing healthy breakfast at school. Attention should also be attached to children who had breakfast previously to avoid a higher intake of energy that might aggravate the situation and would be counterproductive in obesity prevention.
In summary, our study contributes to the body of evidence that exits for factors associated with skipping breakfast in primary schoolchildren. We identified vulnerable groups for targeted prevention and behavioral aspects, which need to be addressed in addition with preventing children from skipping breakfast. Therefore, the current results play an important role for developing targeted preventive measures for skipping breakfast in primary schoolchildren.
Strengths and limitations
This research provides a valuable contribution in exploring determinants for the prevention of skipping breakfast in schoolchildren. However, some aspects should be considered when interpreting these findings.
Anthropometric measurements of the children were taken in a standardized manner according to a protocol by specially trained staff. Data management and statistical advice was provided by the Institute of Epidemiology and Medical Biometry at Ulm University. However, a limiting factor is the cross-sectional character of this research that precludes any causal interpretations of the results because cross-sectional studies do not allow conclusions about the direction of the detected associations.
Parents did not completely fill in questionnaires therefore missing values occurred. In observational studies, missing data are a frequently arising problem and may possibly bias the results. Therefore, the study examined the specific differences between those participants with missing and those with complete data. Considering these differences, children with missing data show several critical characteristics: They have higher rates of migration background and abdominal obesity, and less frequently a tertiary educational level. If these participants could have been included in the regression analysis for correlates of skipping breakfast, it might have accentuated the results. In this research, only schoolchildren whose teachers gave their agreement to participate were involved. Furthermore, due to the voluntary participation, only 62% of parents of eligible children gave their consent. Thus data from over a third of eligible children could not be collected. It may be assumed that there are differences between children who participated in the study and those who failed. This may contribute to the missing data bias.
In common with studies with an observational character, some unintentional bias may compromise the results. As already mentioned, only schoolchildren whose teachers and parents gave their agreement to participate were studied. Therefore, a twofold selection bias may have occurred on behalf of the teachers deciding to opt in and parents giving their consent for participation. Recall bias and social desirability bias may affect the parental report concerning the offspring’s patterns of physical activity, screen media use and consumption of soft drinks as well as breakfast habits. Parental breakfast was not assessed in the present study, but should be included in future research. Furthermore, the way skipping breakfast was assessed is a limitation of the study. Although the results are not representative for the whole of Germany, the sample size and the fact that this research comprises of data from an entire federal state of Germany are great strengths of the study. Response rates from participating parents with 87% at baseline were remarkably high. The study thus provides a valuable contribution for exploring determinants in the prevention of skipping breakfast in schoolchildren.