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Journal of the American College of Nutrition, Vol. 17, No. 1, 19-24 (1998)
Published by the American College of Nutrition

Review Article

The Importance of Breakfast in Meeting Daily Recommended Calcium Intake in a Group of Schoolchildren

Rosa M. Ortega, PhD, FACN, Ana María Requejo, PhD, Ana M. López-Sobaler, PhD, Pedro Andrés, PhD, M. Elena Quintas, Beatriz Navia, Mercedes Izquierdo and Trinidad Rivas

Departamento de Nutrición (R.M.O., A.M.R., A.M.L-S., E.Q., B.N., M.I.), Facultad de Farmacia, Universidad Complutense, Madrid
Laboratorio de Técnicas Instrumentales (P.A.), Facultad de Farmacia, Universidad Complutense, Madrid
Departamento de Higiene Alimentaria (T.R.), Exmo. Ayuntamiento de Madrid Madrid SPAIN

Address reprint requests to: Rosa M. Ortega, PhD, Departamento de Nutricion, Facultad de Farmacia, Universidad Complutense de Madrid, 28040 Madrid SPAIN


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Objective: To evaluate the breakfast intake of calcium and milk products and to determine whether these correlate with total intake of both calcium and milk products.

Methods: Food taken at breakfast and throughout the day was recorded using a 7 consecutive day food record in 200 schoolchildren aged between 9 and 13 years.

Results: 65.3% of boys and 80.5% of girls showed intakes of calcium which were lower than recommended. Milk products were the foods most frequently included in breakfast (95.5% of subjects included them in this meal). A relationship was seen between energy provided by breakfast and the quantities of milk products (r=0.5735) and calcium (r=0.6908) taken at this meal. A relationship was also seen between energy provided by breakfast and daily intake of milk products (r=0.4633) and calcium (r=0.4954). The percentage of intakes of calcium lower than those recommended decreased when breakfast provided >=20% of total energy intake, and when the consumption of milk products at breakfast was greater than the 50th percentile (200 ml). Subjects with breakfast milk product intakes >=200 ml showed higher intakes of the same over the rest of the day (233.3±140.4 g) than did those who took lesser quantities of these foods at breakfast (161.5±100.6 g). Further, those who took >=25% of the recommended intake of calcium at breakfast showed greater intakes of the same over the rest of the day (600.4±213.8 mg compared to 510.8±200.7 mg in subjects with lower calcium intakes).

Conclusions: The intake of milk products (r=0.7587) and calcium (r=0.7223) at breakfast correlates with the consumption of these foods in the whole diet. However, the total daily intake of milk products and calcium does not depend solely on breakfast intake. Subjects with the greatest intakes at breakfast also showed greater intakes over the rest of the day (r=0.3953 for milk products and r=0.4122 for calcium).

Key words: breakfast, calcium intake, schoolchildren, milk products


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
It is of prime importance to monitor the intake of milk products and calcium in young and adolescent children to meet the high nutritional needs associated with growth and to safeguard health in later life [1].

Several studies have shown that an adequate calcium intake allows the production of a greater bone mass—a factor that retards the appearance of osteoporosis [2–5]. It is also of use in the prevention of cancer of the colon [6–9], hypertension [10,11], and hypercholesterolaemia [12].

Changes in eating habits are seen during adolescence since young people begin to make their own decisions about what they wish to eat. They frequently choose sweet drinks instead of milk [3], and since they begin to worry about their appearance it is common for adolescents to restrict their intake of foods [13]. Their intakes of milk products and calcium are frequently lower than those recommended [14–18].

Breakfast frequently includes milk products and this meal therefore supplies an important quantity of the total calcium provided by the diet. The aim of the present investigation was to evaluate the breakfast intake of calcium and milk products and to determine whether these intakes impact total consumption over the rest of the day.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
The study subjects were 200 schoolchildren aged between 9 and 13 years studying at two schools in Madrid. Subjects belonged to either a middle or low socioeconomic level.

The selection of the two schools was performed by the Madrid City Hall (Dept. of Health and Consumer Affairs) [Exmo. Ayuntamiento de Madrid (Área de Salud y Consumo)], through whom contact with the centers was made. A preliminary selection of schools was made bearing in mind the number of students and the socioeconomic level of each center, whether a school canteen was available and if present, whether a sufficiently high number of children ate there. From the centers that met preliminary selection requirements, which also included that the school populations be of middle or low socioeconomic status, those that finally took part were chosen at random. Permission to perform the study was sought from the Directors of the two schools selected, from the School Council and from the Parents’ Association of each center.

Eight class groups were chosen at random from each center. Participation was requested of those children who ate at the school canteen (a total of 334 students). The parents of the selected children were invited to attend a meeting where the nature of the study was explained and their signed consent was sought. Of those selected, 210 students (62.9%) finally agreed to participate.

Exclusion criteria included those suffering of any disease or disorder that might modify the results of the parameters under study e.g., hypercholesterolaemia, hypertriglyceridaemia, diabetes or other endocrine disorders and inadequate renal function. Other exclusion criteria included the consumption of drugs such as glucocorticoids, diuretics and steroids, absence at the time of the study and lack of consistency in answers given in the different tests performed. Once exclusions were made the final experimental population stood at 200 subjects (59.9% of those originally selected).

This study was approved by the Research Committee of the Facultad de Farmacia, Universidad Complutense de Madrid.

Diet Study
Food intake at breakfast and over the rest of the day was monitored using a food record for 7 consecutive days. Subjects and their parents received instructions about how the questionnaire should be completed. They were informed that all foods taken over the course of each study day should be recorded, including all drinks and sweets etc., and if possible that these be weighed or recorded using traditional household quantities (cups, spoonfuls, etc.). Kitchen scales were provided to parents who needed them.

Given that the subjects took their midday meal in the school canteen for 5 of the 7 days of the study (Monday through Friday), the monitoring of foods taken at these times was performed by "precise individual weighing." Trained personnel weighed the food served to each subject and they also weighed the food left over by each.

Data of foods taken were transformed into values of energy and nutrients using Tables of Food Composition published by the Instituto de Nutrición [19]. Observed intakes were compared to recommended intakes (RI) in order to evaluate the adequacy of the diet [20].

Anthropometric Study
Weight and height were determined using a digital electronic weighing scale (Seca alpha; Rue Lavoisier 91430, Igmy, France; range: 0.1 to 150 kg) and a digital stadiometer (Harpender Pfifter 450; Badem, Padum Aveny, Carlstadt, NJ, USA) (range: 70 to 205 cm), respectively. From the anthropometric data the body mass index (BMI) was calculated. Measurements were made first thing in the morning at the participating schools. Following the norms of the World Health Organisation (WHO) [21], measurements were taken with subjects dressed only in underwear and without shoes.

Socioeconomic Study
In order to select schools that could be considered to have student populations of middle and low socioeconomic level, the monthly fee paid by parents and the characteristics of the school’s home neighborhood were taken into consideration. The socioeconomic status of individual subjects was established considering the professions of the parents and the characteristics of their homes [22]. The data collected confirmed the socioeconomic status of subjects as middle and low.

Statistics
Where distribution of results was homogeneous, differences between means were investigated by the Student "t" test. Where distribution of results was not homogeneous, differences between means were investigated by the Mann-Whitney test. Linear correlation coefficients were also calculated between different diet data.

Differences between the sexes with respect to the intake of milk products or the energy provided by breakfast were established using two way ANOVA.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
The subjects (which included 118 boys and 82 girls) showed no significant differences in age, weight, height or body mass index (BMI) (Table 1).


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  		Table 1. Characteristics of the Sample of Schoolchildren (Mean±SD)

 
Though the mean intake of calcium at breakfast was greater than the 25% recommended, 33.9% of boys and 32.9% of girls showed values below this level. More importantly, 65.3% of boys and 80.5% of girls did not consume the recommended daily intake of calcium (Table 2). A correlation was seen between the intake of milk products (r=0.7587) and calcium (r=0.7223) at breakfast and in the whole diet.


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  		Table 2. Breakfast and Whole Diet-Daily Intakes of Milk Products and Calcium (Mean±SD)

 
Milk products were the foods most frequently included in breakfast (95.5% of subjects included them in this meal). A relationship was seen between the energy supplied by breakfast and the quantity of milk products (r=0.5735) and calcium (r=0.6908) contained in this meal. However, a relationship was also seen between energy supplied by breakfast and daily consumption of milk products (r=0.4633) and calcium (r=0.4954).

Breakfasts that supplied <20% of total energy intake also included lower quantities of milk products and calcium than did larger breakfasts. However, subjects whose breakfasts provided <20% of their total energy intake also consumed fewer milk products and less calcium over the rest of the day. Their dietary calcium density (mg/1000 kcal) and index of nutritional quality (INQ) (observed density/recommended density) with respect to calcium were also lower (Table 3).


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  		Table 3. Breakfast and Whole Diet-Daily Intakes of Milk Products and Calcium with Respect to Breakfast Energy Provision (Mean±SD)

 
When breakfast included a quantity of milk products >50th percentile (200 ml), significant greater intakes were seen in the supply of milk products and calcium at breakfast and in the whole diet, dietary calcium density and INQ with respect to calcium, when compared to breakfasts containing lower intakes of milk products (Table 4).


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  		Table 4. Differences in Daily Intake of Milk Products and Calcium with Respect to Breakfast Milk Product Intake (Mean±SD)

 
The percentage of subjects with calcium intakes lower than those recommended was less when breakfast supplied >=20% of total energy and when the intake of milk products at breakfast was above the 50th percentile (200 ml) (Tables 3 and 4).

Subjects who took >=200 ml of milk products at breakfast showed greater intakes over the rest of the day (233.3±140.4 g) than those who took lesser quantities at this meal (161.5±100.6 g). Further, those who took >=25% of calcium RI at breakfast showed higher calcium consumption over the rest of the day (600.4±213.8 mg compared to 510.8±200.7 mg in those with lower breakfast calcium intake). Therefore, a greater total intake of milk products and calcium does not only depend upon higher quantities taken at breakfast. Subjects with greater intakes at this meal also showed greater intakes over the rest of the day, r=0.3953 for milk products and r=0.4122 for calcium.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The intake of milk products and calcium (Table 2) is similar to that observed in other populations [15–18, 23] but lower than that reported by Löwik et al [24].

65.3% of boys and 80.5% of girls showed calcium intakes lower than those recommended (800 mg/day in children aged 9 and 1000 mg/day in those aged 10 to 13) [20]. These figures (especially that for girl subjects) are quite high (Table 2).

Some authors [25] consider that an intake of 1500 mg/day of calcium during adolescence is necessary to achieve satisfactory bone mass. Using this figure as a guide, the number of insufficient calcium intakes observed is considerably greater (Table 2).

Different studies have associated suboptimal calcium intakes with an increased risk of osteoporosis [2–5], cancer of the colon [6–9], hypercholesterolaemia [12] and high blood pressure [26]. It would therefore seem advisable that this population increase its intake of milk products, and in turn increase its calcium intake (Tables 2–4).

The School Breakfast Program (SBP) reports that it is advisable to take 25% of the daily recommended intake of energy and nutrients during this meal [27]. Using this figure as a guide, 33.9% of boys and 32.9% of girls in the present study show calcium intakes below 25% RI [20] (Table 2). Those subjects with breakfast calcium intakes lower than recommended also showed lower total calcium intakes (692.3±232.9 mg/day) than did other subjects (940.7±266.6 mg/day, r=0.7223).

The influence of breakfast energy intake on calcium intake was studied since breakfast is the meal in which milk products are most commonly taken [28,29]. In a previous study, it was found that 92.9% of 742 subjects included milk products in their breakfasts. It might therefore be considered that breakfast composition play an important role in maintaining a satisfactory calcium intake [29].

In the present study, milk products were included in 95.5% of subjects’ breakfasts. A relationship was found between the energy supplied by this meal and the amount of milk products taken (r=0.5735), and also with the amount of milk products in the whole diet (r=0.4633).

Andersen et al [30], Morgan et al [31] and Nicklas et al [32] showed that the supply of nutrients from breakfast is very important. Children who omitted breakfast did not compensate for this loss of nutrients at other meals. Data such as these confirm the importance of breakfast in the maintenance of an adequate diet in schoolchildren. Hanes et al [28] also found that children who habitually took breakfast showed greater intakes of nutrients than did children who omitted this meal. This was especially evident for calcium, perhaps because of the large supply of milk products commonly taken at this meal.

As indicated by Sampson et al [33] in their study of 1151 children of low socioeconomic status, the omission of breakfast, or the consumption of an inadequate breakfast, is associated with the appearance of substantial deficits of many nutrients. Therefore, campaigns to ameliorate the nutritional status of children should include education programs aimed at improving their breakfasts.

In agreement with these authors, the present study showed that breakfast energy intake plays an important role in milk product and calcium supply both at breakfast and in the diet as a whole (Table 3).

Additionally the intake of milk products and calcium during breakfast influences the total daily intake of milk products & calcium. It was found that subjects whose consumption of milk products at breakfast was above the 50th percentile (200 ml) showed greater intakes of milk products and calcium in the diet as a whole (Table 4). However, differences in total diet were not due solely to breakfast intake of milk products. Those subjects who showed greater breakfast milk product intakes also showed greater intakes over the rest of the day. Our results agree with those of other authors [29,33,34] who have found that the type of breakfast affects food habits and food intake throughout the day.

Resnicow [35] relates the omission of breakfast with increased cholesterolemia. The results of this author, from studies with 500 schoolchildren aged between 9 and 19 years, suggest that encouraging breakfast-skipping schoolchildren to change this habit can improve their nutritive status and, possibly, reduce the risk of future cardiovascular disease [35].

Some studies have shown that dietary calcium, which increases the fecal excretion of cholesterol [36], might have an effect in protecting against hypercholesterolaemia [12]. Sharlin et al [37] have demonstrated the existence of a negative correlation between calcium intake and serum cholesterol levels in males.

In view of this it might be asked whether the nutrients supplied by breakfast, in particular calcium, may be a contributing factor in the increased hypercholesterolemia described by Resnicow [35] in children who omitted breakfast.

Increasing the consumption of milk products at breakfast could increase their intake at other times during the day. However, the observed relationship between breakfast intake and total consumption of milk products could simply be a reflection of a greater total consumption by these subjects. In either case, and given the number of subjects who showed intakes below those recommended, it would seem advisable to increase the quantities of milk products taken at breakfast and over the rest of the day. To achieve this goal, it is necessary to further analyze how children acquire healthy food habits [38] in order to best prepare appropriate education campaigns.


   ACKNOWLEDGMENTS
 
This study was possible through the collaboration of the Exmo. Ayuntamiento de Madrid (Área de Salud y Consumo) and Danone, S.A. which provided the financial support. Our most sincere gratitude to Dr. D. Simón Viñals Pérez (Concejal Delegado del Área de Salud y Consumo), Dr. D. Angel Gómez Mascaraque (Director de Servicios de Higiene y Salud Pública) and D. Juan Ignacio Rojas Ponce (Director de Servicios de Consumo, Ordenación Alimentaria y Salubridad Pública) of the Exmo. Ayuntamiento de Madrid, and to D. Jose Antonio Mateos Guardia (Jefe del Servicio de Alimentación y Nutrición y de Estrategia Reglamentaria de Danone, S.A.).

Received December 1, 1996. Accepted July 1, 1997.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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