The contribution of breakfast cereals to the nutritional intake of the materially deprived UK population

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1 (2012) 66, & 2012 Macmillan Publishers Limited All rights reserved /12 ORIGINAL ARTICLE The contribution of breakfast cereals to the nutritional intake of the materially deprived UK population BA Holmes 1, N Kaffa, K Campbell and TAB Sanders King s College London, Diabetes & Nutritional Sciences Division, School of Medicine, London, UK Background/Objectives: Breakfast is an important source of micronutrients in the diet and its consumption has been linked to positive health outcomes. The present analysis investigated the contribution that breakfast cereals make to the nutrient intakes of the materially deprived (low income) UK population. Subjects/Methods: Data for 3728 respondents aged 2 years and over from the UK Low Income Diet and Nutrition Survey ( ) were analysed. Nutrient intakes of consumers and non-consumers of breakfast cereal were compared. Results: Breakfast cereals were consumed by 49% of men, 58% of women, 80% of boys and 80% of girls, and median intakes were: 35, 25, 29 and 21 g/d, respectively. Consumers of breakfast cereals had higher intakes of thiamin, riboflavin, niacin, biotin, folate, vitamin B 6, vitamin B 12, iron and zinc than non-consumers. Breakfast cereal consumption was also related to higher intakes of calcium, attributable to higher milk consumption. The intake of wholegrain and high-fibre breakfast cereals was associated with a higher intake of non-starch polysaccharides. Intakes of niacin, biotin, calcium and zinc were higher but that of vitamin B 6 was lower among consumers of exclusively wholegrain and high-fibre breakfast cereals compared with consumers of other breakfast cereals. There were no significant differences observed in intakes of non-milk extrinsic sugars according to type of breakfast cereal consumed. Conclusions: Breakfast cereals make a significant contribution to the micronutrient intake of the low-income UK population. (2012) 66, 10 17; doi: /ejcn ; published online 10 August 2011 Keywords: breakfast cereal; fibre; low income; UK Introduction Breakfast consumption, in particular breakfast cereal consumption, has been linked to higher micronutrient intakes and positive health outcomes (Nicklas et al., 2004; Song et al., 2006; Van den Boom et al., 2006; Wilson et al., 2006; Williams, 2007; Albertson et al., 2008). There is evidence to suggest that lower-income or disadvantaged populations may be less likely to consume breakfast (Keski-Rahkonen et al., 2003), particularly children and adolescents Correspondence: Dr BA Holmes, Danone Research, Global Nutrition Department, RD 128, Palaiseau Cedex 91767, France. bridget.holmes@danone.com 1 Current address: Danone Research, Global Nutrition Department, Palaiseau Cedex, France. Contributors: BH was involved in all stages of LIDNS, the analysis and the manuscript. TS was involved in the scientific report carried out at Kings College London, the analysis and the manuscript. NK and KC were involved in the scientific report and commented on the manuscript. Received 19 April 2010; revised 27 June 2011; accepted 28 June 2011; published online 10 August 2011 (O Dea and Caputi, 2001; Moore et al., 2007; Timlin et al., 2008; Merten et al., 2009; Deshmukh-Taskar et al., 2010). It has also been suggested that they are more likely to consume less healthful breakfasts that do not include fruits or cereals (Moore et al., 2007). Cereal grains, especially wholegrains, are a rich source of B-complex vitamins, and breakfast cereals in the United Kingdom (UK) are also often fortified with vitamin D, folic acid, vitamin B 12, iron and zinc (Williamson, 2010). Several reports have indicated that consumers of breakfast cereal have higher micronutrient intakes compared with nonconsumers, and are thus more likely to meet micronutrient recommendations especially for riboflavin, folate, vitamin B 6, calcium, zinc and iron (Crawley, 1993; Nicklas et al., 1998, 2004; Galvin et al., 2002; Van den Boom et al., 2006). However, breakfast cereals are usually consumed with milk, which is a significant source of calcium and riboflavin, and this is likely to be an important determinant of the higher calcium and riboflavin intake reported among consumers. Consumption of breakfast cereals is associated with higher

2 intakes of several micronutrients in preschool children (Ruxton and Kirk, 1997), school children and adolescents (Crawley, 1993; Nicklas et al., 1993, 1995; Gibson and O Sullivan, 1995; Ruxton et al., 1996; Van den Boom et al., 2006; Williams, 2007; Deshmukh-Taskar et al., 2010), and adults (McNulty et al., 1994). Breakfast consumption is also associated with higher intakes of fibre (Ruxton and Kirk, 1997; Barton et al., 2005; Rampersaud et al., 2005; Van den Boom et al., 2006). The Low Income Diet and Nutrition Survey (LIDNS), a national survey of materially deprived (low-income) individuals in the UK, showed that the consumption of wholegrain and high-fibre (WGHF) breakfast cereals was lower for deprived individuals compared with the UK general population (National Diet and Nutrition Surveys (NDNS)) for the majority of age and sex groups (boys 46% vs 52%, girls 42% vs 45%, years: men 24 31% vs 46%, women 27 37% vs 50%, 65 years and over: men 48% vs 51%, women 52% vs 50%) (Finch et al., 1998; Henderson et al., 2002; Nelson et al., 2007; Bates et al., 2009). Breakfast cereals contributed less to non-starch polysaccharide (NSP) intakes in adults in LIDNS compared with NDNS (19 64 years: men 4% vs 11%, women 5% vs 12%, 65 years and over: men 9% vs 12%, women 9% vs 13%) (Henderson et al., 2003a; Nelson et al., 2007). The contribution of WGHF breakfast cereals to NSP intakes in children aged 4 18 years in LIDNS was also lower than in NDNS (boys 7% vs 10%, girls 5% vs 8%) (Gregory et al., 2000; Nelson et al., 2007). In LIDNS, breakfast cereals contributed significantly to intakes of iron in the lowincome population 12% in men, 15% in women, 26% in boys and 23% in girls (of which 6, 8, 12 and 9%, respectively, came from WGHF breakfast cereals). In men and women in NDNS, 3 20% of micronutrient intakes came from breakfast cereals, with significant contributions to intakes of B vitamins (8 16%) and vitamin D (12 14%) (Henderson et al., 2003b). Differences between the surveys in age groups for children (LIDNS 2 18 years, NDNS 4 18 years) as well as methodological differences described elsewhere (Nelson et al., 2007) should be noted. Although breakfast cereals generally contributed less to the diets of the low-income population compared with the general population, the contribution made to intakes is likely to be important, particularly for some subgroups, and warranted further investigation. The aim of the present analysis was to investigate further the contribution that breakfast cereals make to the nutrient intakes of the low-income UK population by comparing breakfast cereal consumers with non-consumers, and by comparing the nutrient intakes of breakfast cereal consumers according to the type of cereal consumed. Materials and methods The present study is based on secondary analysis of data collected in LIDNS. LIDNS was commissioned by the UK Food Standards Agency to provide a comprehensive picture of the food consumption and nutritional status of a nationally representative sample of respondents living in low-income households in the UK. Details of the full LIDNS methodology (including weighting and survey design) and results are provided in the main survey report (Nelson et al., 2007). Briefly, a nationally representative sample of lowincome households was identified using an index of material deprivation assessed using a doorstep screening questionnaire. This questionnaire was based on markers of material deprivation including receipt of benefits, household composition, car ownership and employment status. In eligible households, up to two respondents per household were randomly selected to take part in the survey. The survey sample used a multistage clustered design, selected in stages, with the cluster hierarchy being: wards, addresses, households and individual respondents. The target population to screen-in was the 15% most deprived households in the UK. In order to account for over-sampling in certain areas and to ensure that the correct population proportions were used in the analysis, the final dataset was weighted so that the reported findings reflect the demographic characteristics of the UK low-income population as a whole. The key stages of the survey, administered by trained interviewers and nurses, involved a face-to-face interview and self-completion questionnaire, dietary data collection, anthropometric measurements (which varied by age) and the collection of blood samples (in those 8 years and over) to measure indices of nutritional status. Fieldwork was carried out in five fieldwork waves from November 2003 to January Results are based on a sample of 3728 respondents (unless specified otherwise), 37% males and 63% females, aged 2 and over. Dietary data collection used a 24-h recall multiple pass method repeated on four non-consecutive days within a 10-day period, including 1 weekend day where possible. The method was based on the principle used in the United States (Moshfegh et al., 1999) but modified for use in the Low Income Diet Methods Study (Nelson et al., 2003) and again for LIDNS. Information was collected in multiple phases within a single interview, allowing the respondent several opportunities to recall what they ate and drank over the previous 24-h period. Portion size was estimated using packet weights, number of items, a photographic food atlas (Nelson et al., 1997) or household measures. Where possible, one of the four 24-h recalls was conducted over the telephone. Respondents providing three or four 24-h recalls were considered to be fully productive and were included in the analysis. Productive interviews were held with 55% of eligible individuals. Of the fully productive individuals, 3656 completed all 4 recall days and 72 completed 3 days. For each respondent, the mean food and nutrient intakes were computed over the 3 or 4 days of data (as appropriate). The mean and median estimates of intake for the whole sample and sample subgroups were then 11

3 12 computed using these mean values for each respondent (Nelson et al., 2007). Intakes of nutrients were calculated from the records of food consumption using a specially adapted nutrient databank developed for the UK NDNS (Gregory et al., 1990; Gregory et al., 1995, 1998, 2000; NDNS, 2003) and modified for LIDNS with many nutrient values updated (including new analytical values for breakfast cereals), and new codes added to accommodate new products that had become available and additional homemade recipes. The following groups were created for the analysis after a review of the LIDNS data according to breakfast cereal consumption, and after discussions between the authors considering the aims of the analysis: Consumers and nonconsumers of breakfast cereals (consumers were defined as respondents who consumed breakfast cereal, regardless of quantity, frequency or type, at some point over the 4-day recording period), WGHF breakfast cereal consumers, and other breakfast cereal consumers. WGHF breakfast cereals included cereals with an NSP (Englyst fibre) content of X4 g/ 100 g, for example, All Bran, muesli, Shredded Wheat and including porridge and Ready Brek. Other breakfast cereals, not wholegrain or high-fibre included cereals with an NSP (Englyst fibre) content of o4 g/100 g, for example, cornflakes, rice crispies, Coco Pops, Sugar Puffs. Consumers according to cereal type were identified as a result of food groupings used in LIDNS (Nelson et al., 2007), based on those used in NDNS (Henderson et al., 2002). Respondents consuming both types of cereal (WGHF and other breakfast cereals) were excluded from the analysis comparing the two types of cereal consumers. Overall, 485 subjects (unweighted) consumed both types of cereal and were excluded from these analyses (representing 13% of the full sample, 6% of children and 7% of adults). Data analysis was carried out using SPSS Version 17.0 (SPSS Inc, 2010). Multivariate analysis of variance was used to test for differences between consumers and non-consumers by age group, and comparisons between subgroups use a Bonferroni post-hoc test that was only conducted where there was a statistically significant interaction between the age and gender group, and cereal intake category. In order to minimize spurious statistical significance from multiple tests, Po0.01 was set to signify statistical significance. Comparisons between the proportions of participants meeting the reference nutrient intakes for micronutrients were done with Pearson s w 2 -test. All values are weighted unless specified otherwise. Nutrient intake data excludes dietary supplements. No adjustments were made in the analysis for mis-reporting of data. Boys and girls refer to those aged 2 18 years, and men and women refer to those aged 19 years and over. Results Table 1 shows the mean age and body mass index of the study population according to reported breakfast cereal consumption. Fewer men consumed breakfast cereal than women (49% vs 58%) (Table 2). Men aged years were the least likely to be consumers of breakfast cereals (35%), and women aged 65 years and over were most likely to be consumers (72%). On an average 24% of men and 27% of women reporting being consumers of only WGHF breakfast cereals accounting for 44 and 41% of breakfast cereal consumers, respectively. Boys and girls aged 2 18 years were more likely to consume breakfast cereals (both 80%). The proportion of consumers was greater among younger children aged 2 10 years (89% of boys and 88% of girls) compared with 67 and 70% in boys and girls aged years. WGHF breakfast cereals were consumed by 20% of boys and 19% of girls accounting for 36 and 29% of breakfast cereal consumers, respectively, a lower proportion than observed in adults. The median intake among consumers of breakfast cereals was 10 g greater in men than women and 4 g and 7 g greater in boys than women and girls respectively. The median intake among consumers of WGHF breakfast cereals was 10 g higher in men than women and 10 g higher in boys than girls. Breakfast cereal consumers vs non-breakfast cereal consumers Energy intakes did not differ between consumers and nonconsumers of breakfast cereals (Table 3). The proportion of Table 1 Age and BMI of adults (19 years and over) and children (2 18 years) in the LIDNS survey, by cereal consumers and non-consumers Cereal consumer Men Women Boys Girls Yes No Yes No Yes No Yes No Age (years) n (unweighted) Mean (s.d.) 54.7 (19.8) 48.1 (18.4) 54.6 (21.2) 46.0 (18.7) 8.9 (4.3) 11.8 (4.8) 8.6 (4.5) 12.1 (4.2) BMI (kg/m 2 ) n (unweighted) Mean (s.d.) 27.0 (5.1) 27.3 (5.3) 28.1 (6.1) 28.0 (7.1) 18.7 (4.2) 20.5 (4.7) 19.2 (4.2) 20.9 (4.0) Abbreviations: BMI, body mass index; LIDNS, Low Income Diet and Nutrition Survey. No statistical difference in BMI according to breakfast cereal consumption: univariate analysis of variance adjusted for age and gender.

4 Table 2 Mean daily intake of breakfast cereals (grams/day) by adults (19 years and over) and children (2 18 years) in the LIDNS survey in all participants and in consumers only 13 All breakfast cereals WGHF breakfast cereals only Men Women Boys Girls Men Women Boys Girls All participants n (unweighted) Mean (s.d.) 28.3 (59.1) 22.5 (40.0) 29.8 (33.7) 22.8 (30.7) 22.4 (58.3) 17.0 (39.4) 15.8 (31.2) 12.4 (29.6) Median Consumers only n (unweighted) % consumers Mean (s.d.) 58.0 (73.8) 39.1 (46.2) 37.4 (33.8) 28.5 (31.9) 72.7 (89.7) 48.6 (54.4) 43.1 (46.8) 34.1 (48.4) Median Abbreviations: LIDNS, Low Income Diet and Nutrition Survey; WGHF, wholegrain and high fibre. Table 3 Mean daily intake of selected nutrients by adults (19 years and over) and children (2 18 years) in the LIDNS survey according to reported consumption of breakfast cereals Cereal consumer Men Women Boys Girls P-value a Yes No Yes No Yes No Yes No n (unweighted) Energy (MJ/day) 8.95± ± ± ± ± ± ± ± b Protein (% en) 16.2± ± ± ± ± ± ± ± Total fat (% en) 35.4± ± ±6.6** 36.6± ±4.8** 38.3± ± ± b Saturated fat (% en) 13.7± ± ± ± ± ± ± ± Carbohydrate (% en) 48.3± ± ± ± ± ± ± ±5.8 o NMES (% en) 13.4±7.0* 15.6± ± ± ±6.6* 14.9± ± ±8.4 o b NSP (g) 13.9±5.3** 11.5± ±4.6** 9.6± ± ± ± ±3.5 o b Thiamin (mg) 1.84± ± ± ± ± ± ± ±0.48 o Riboflavin (mg) 2.11± ± ± ± ± ± ± ±0.38 o Niacin (mg) 11.6± ± ± ± ± ± ± ±2.2 o Folate (mg) 306± ± ±94 178±79 222±89 162±69 197±69 146±55 o Biotin (mg) 34.9± ± ±10.1** 22.0± ± ± ± ±7.8 o Vitamin B 6 (mg) 2.5± ± ± ± ± ± ± ±0.6 o Vitamin B 12 (mg) 6.6± ± ± ± ± ± ± ±1.7 o Vitamin D (mg) 3.7±2.5** 2.9± ± ± ± ± ± ± b Calcium (mg) 1000± ± ± ± ± ± ± ±233 o Iron (mg) 12.4± ± ± ± ± ± ± ± Zinc (mg) 9.5± ± ±2.6** 6.5± ± ± ± ±2.1 o Abbreviations: LIDNS, Low Income Diet and Nutrition Survey; NMES, non-milk extrinsic sugars; NSP, non-starch polysaccharide; % en, percentage of energy. Mean values±s.d.; *Po0.01 and **Po0.001 compared consumers with non-consumers using a Bonferroni multiple comparison test only if the consumer/nonconsumer group interaction was Po0.01. a Probability is from multivariate analysis of variance with consumer/non-consumer and age group as factors. b A significant age group consumer/non-consumer interaction. energy derived from fat was 1 2% lower and that derived from carbohydrates correspondingly higher. There were no consistent differences between consumers in the intake of non-milk extrinsic sugars (NMES) with intakes lower in men but greater in boys who were consumers. Mean intakes of NSP were significantly higher in consumers of breakfast cereals for men and women, but no significant differences were noted among children. Mean intakes of thiamin, riboflavin, niacin, biotin, vitamin B 6, vitamin B 12, folate, calcium, iron and zinc were consistently higher in the consumers of breakfast cereals for all groups. The high calcium intake is unlikely to be attributable to cereal intake as cereals are a poor source of calcium. Milk intake was significantly greater (Po ) among consumers of breakfast cereals compared with non-consumers. The mean daily intake of milk in ml with 99% confidence interval for consumers vs non-consumers were: men 290 (268, 312) vs 160 (139, 181); women 234 (220, 250) vs 153 (136, 171); boys 267 (247, 288) vs 155 (114, 196); girls 202 (181, 223) vs 101 (58, 144).

5 14 In both consumers and non-consumers of breakfast cereals, average micronutrient intakes generally exceeded the UK reference nutrient intake with some exceptions including iron, folate, zinc in some groups. A significantly higher proportion of respondents who consumed breakfast cereals met the reference nutrient intake for micronutrients Table 4 Proportions (%) of adults (19 years and over) and children (2 18 years) in the LIDNS survey meeting the UK RNI for selected micronutrients according to reported consumption of breakfast cereals Cereal consumer Men Women Boys Girls Yes No Yes No Yes No Yes No n (unweighted) Thiamin 97** 72 92** 78 98** 84 98** 81 Riboflavin 86** 55 83** 46 85** 37 82** 31 Niacin equivalents 98** 93 99** ** Folate 85** 58 62** 29 84** 43 76** 25 Vitamin B 6 94** 73 88** 70 97** 67 98** 79 Vitamin B 12 99** 95 97** ** 91 99** 93 Calcium 80** 55 54** 33 69** 38 67** 39 Iron 83** 54 38** 10 61** 15 38** 13 Zinc 48** Abbreviations: LIDNS, Low Income Diet and Nutrition Survey; RNI, reference nutrient intake. **Po0.001 compared with non-consumers using a w 2 -test. with the greatest differences observed for riboflavin, folate and iron (Table 4). WGHF breakfast cereal consumers vs other breakfast cereal consumers Table 5 shows the comparison between consumers of WGHF breakfast cereals and consumers of other cereals. In contrast to the results of the consumers vs non-consumers of breakfast cereals, there were few statistically significant differences. Overall the intakes of NSP, niacin, biotin, calcium and zinc, and the proportion of energy derived from protein were higher in those consuming WGHF cereals. Intakes of vitamin B 6 on the other hand tended to be lower in the male participants consuming WGHF cereals. There were no significant differences in NMES between groups. Discussion The analyses allowed comparisons to be made between nutrient intakes of the low-income UK population according to breakfast cereal consumption. The results highlight the important contribution that breakfast cereals appear to make to the daily nutrient intakes of consumers in the low-income population. The results showed that the proportion of energy derived from fat was 1 2% lower and that of Table 5 Mean daily intake of selected nutrients by adults (19 years and over) and children (2 18 years) in the LIDNS survey according to whether they reported consuming WGHF or other breakfast cereal Cereal type Men Women Boys Girls P-value a WGHF Other WGHF Other WGHF Other WGHF Other n (unweighted) Energy (MJ/day) 8.89± ± ± ± ± ± ± ± Protein (% en) 16.6± ± ± ± ± ± ± ± Total fat (% en) 35.5± ± ± ± ± ± ± ± Saturated fat (% en) 13.6± ± ± ± ± ± ± ± Carbohydrate (% en) 47.9± ± ± ± ± ± ± ± NMES (% en) 12.9± ± ± ± ± ± ± ± NSP (g) 15.6± ± ± ± ± ± ± ±4.0 o Thiamin (mg) 1.8± ± ± ± ± ± ± ± Riboflavin (mg) 2.0± ± ± ± ± ± ± ± Niacin (mg) 10.6± ± ± ± ±6.9* 8.4± ± ± b Folate (mg) 301± ± ±88 223±93 224±93 200±73 187±65 200± b Biotin (mg) 36.6± ± ± ± ± ± ± ±13.9 o Vitamin B 6 (mg) 2.4±0.9* 2.6± ± ± ±1.0* 2.2± ± ±0.6 o0.009 b Vitamin B 12 (mg) 6.7± ± ± ± ± ± ± ± Vitamin D (mg) 3.7± ± ± ± ± ± ± ± Calcium (mg) 1009± ± ± ± ± ± ± ± Iron (mg) 12.1± ± ± ± ± ± ± ± Zinc (mg) 9.9± ± ± ± ± ± ± ± Abbreviations: LIDNS, Low Income Diet and Nutrition Survey; NMES, non-milk extrinsic sugars; NSP, non-starch polysaccharide; RNI, reference nutrient intake; WGHF, wholegrain and high fibre; % en, percentage of energy. Mean values±s.d.; *Po0.01 and **Po0.001 compared test with other breakfast cereals using a Bonferroni multiple comparison test only if the cereal type x group interaction was Po0.01. a Probability is from multivariate analysis of variance with cereal type and age group as factors. b Denotes a significant age group cereal type interaction.

6 carbohydrate was 1 2% higher in consumers compared with non-consumers with no difference in saturated fatty acid intake between groups. This finding is in agreement with other reports (McNulty et al., 1996; Barton et al., 2005; Song et al., 2006; Deshmukh-Taskar et al., 2010). Skipping breakfast has also been associated with increased snacking, especially of high fat snacks (Kirk et al., 1997; Sjoberg et al., 2003). However, the present study found no evidence to suggest that reported energy intakes or body mass index were higher in non-consumers of breakfast cereals. It is widely believed that breakfast cereals are an important source of NMES and the UK government have imposed restrictions on advertising breakfast cereals on television to children that are high in NMES (Ofcom, 2006). The present study found no consistent association between breakfast cereal intake and intake of NMES. With regard to sugar intakes and breakfast cereal consumption, the evidence in the literature is also conflicting. Sugar intakes were higher in breakfast consumers in some studies (Nicklas et al., 2000; Galvin et al., 2002; Sjoberg et al., 2003) but lower in others (Nicklas et al., 1993) although these studies were not restricted to breakfast cereal. Secondary analysis of NDNS data for children years indicated that children with diets high in breakfast cereals as a percentage of their total energy had a lower proportional intake of NMES, compared with low consumers of breakfast cereals. Consumption of sweetened cereals was, however, positively associated with NMES intake (Gibson, 1999). It has also been suggested that even though some types of breakfast cereals contain added sugar they remain good sources of micronutrients and have a positive impact on diet quality (Gibson, 2003; Gibson and Boyd, 2009). This conclusion is supported by the findings of the present study. Most of the previous studies agree that breakfast consumers are more likely to have a better overall diet quality and nutrient intakes that more often align with current dietary recommendations (Rampersaud et al., 2005). Breakfast consumers have previously been reported to make better choices throughout the day, for example, consuming more vegetables and milk, and less soft drinks (Lattimore and Halford, 2003). Along with the evidence that breakfast consumers make better dietary choices overall, it seems that breakfast and cereal consumption may be one component of an overall healthy lifestyle that helps to maintain adequate nutrient intake, healthy body weight (Barton et al., 2005) and promote positive health outcomes (Albertson et al., 2008). Pilot studies in adults and children suggest that both breakfast frequency and composition may have important effects on a variety of factors, supporting the evidence that a nutritious breakfast is a key factor in promoting healthy body weight, chronic disease risk reduction and positive mental health (Pereira et al., 2011). The separation of the types of breakfast cereals based on NSP content highlighted that consumers of WGHF breakfast cereals had, not surprisingly, a higher intake of NSP. However, there were few significant differences in micronutrient intake. In part this is likely to be a consequence of the widespread voluntary fortification of breakfast cereals with vitamins and minerals in the UK. The addition of vitamins and minerals to breakfast cereals is not permitted in several European countries, notably France and Denmark. Higher intakes of NSP from breakfast cereals have also been linked to high intakes of NSP from other sources (Emmett et al., 1993), indicating that the rest of the diet reflects the choice of cereal. Overall, the analyses demonstrate the benefits of consuming breakfast cereals seen through higher micronutrient intakes in all groups. With the exception of NSP intake, the benefits observed appeared to be apparent regardless of the type of cereal consumed. The findings have implications for dieticians and those who might promote the importance of eating breakfast or run breakfast programs, such as those based in schools. The challenge of promoting the potential benefits of breakfast, particularly with reference to lowincome groups, is to ensure that a distinction is made between promoting a nutrient-rich breakfast cereal, as opposed to simply promoting breakfast per se. The present analysis has some limitations that are acknowledged by the authors. The definition of breakfast cereal consumers means that subjects were identified as consumers if they consumed breakfast cereal at some point over the 4 days for which dietary data were collected. Some subjects will have consumed breakfast cereal only once during the 4 days, while others will have consumed it more regularly, for example, on a daily basis, and possibly even more than once a day. The analysis does not, therefore, take into account any link between frequency of consumption of breakfast cereal, or low and high consumption of breakfast cereal and nutrient intake. Additionally, breakfast cereals may have been consumed at any occasion during the day, that is, not only at breakfast time. Analysis to further investigate nutrient intakes according to frequency of breakfast cereal consumption, low, medium and high levels of intake, and breakfast cereal consumption according to a meal name or predefined time would be an interesting next step. Finally, due to the cross-sectional design of this survey, it is difficult to examine links between breakfast cereal consumption, nutrient intake and BMI, and thus further research in this population conducted over time is needed. Conflict of interest The authors declare no conflict of interest. Acknowledgements LIDNS was funded by the Food Standards Agency and carried out by the National Centre for Social Research, King s 15

7 16 College London, and the Royal Free and University College London Medical School. The literature review and secondary analysis was carried out for Kings College London through additional monies obtained from the Association of Cereal Food Manufacturers (ACFM). The authors gratefully acknowledge the FSA, ACFM and Caroline Lynch from Nexus Communications Group. References Albertson AM, Thompson D, Franko DL, Kleinman RE, Barton BA, Crockett SJ (2008). Consumption of breakfast cereal is associated with positive health outcomes: evidence from the National Heart, Lung, and Blood Institute Growth and Health Study. Nutr Res 28, Barton BA, Eldridge AL, Thompson D, Affenito SG, Striegel-Moore RH, Franko DL et al. (2005). The relationship of breakfast and cereal consumption to nutrient intake and body mass index: The National Heart, Lung and Blood Institute Growth and Health Study. J Am Diet Assoc 105, Bates B, Lennox A, Swan G (2009). National Diet and Nutrition Survey. 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