What's for Breakfast

Should eggs and bacon be on your kid’s breakfast menu?

Parents and nutrition experts agree that skipping breakfast is not a good idea for children or teens before they head off to school or work.  But undoubtedly many of us think that the traditional breakfast of eggs, bacon and a tall glass of OJ is a good way to start the day.  Certainly, that meal provides a lot of protein and vitamin C but it is not ideal––in fact it is an unhealthy diet.  Maybe white bread toast with butter and jam or jelly on it, or a sweet roll, or pancakes drenched in syrup are also on the menu––they too provide less than ideal nutrition

Here is the science:  The atherosclerosis that narrows arteries and causes cardiovascular diseases (CVDs) usually starts in childhood and continues to increase in severity throughout life.  Bacon is high in saturated fat, sodium (salt), and is a processed red meat.  These attributes are associated with development of CVDs, diabetes and cancer.  Like bacon, eggs are high in cholesterol and eating too many of them may also speed the development of CVDs. 

The fruit juice, jam and jellies are high in sugar and low in the healthful fiber found in whole fruits that slows the metabolism of sugar and counteracts the effects of a high level of sugar in the diet.  And white bread is a processed food that is metabolized rapidly.  It also contributes to a spike in insulin, and may lead to hunger if it moves too much sugar out of the bloodstream.  Long-term, high amounts of sugar and highly processed carbohydrates, like white flour and white potatoes, lead to the development of insulin resistance and diabetes.

Red Meat and Processed Meat and Cardiovascular Disease (CVD)
In some studies, both unprocessed and processed meat consumption were associated with higher coronary heart disease risk when meat replaced foods, such as low-fat dairy, nuts, and fish.1  Combined (meta) analysis of prospective studies indicates that high consumption of red meat, especially processed meat, may increase all-cause and CVD mortality and diabetes.2 3  These findings suggest that adverse effects of preservatives (e.g. sodium, nitrites, and phosphates) and/or preparation methods (e.g. high temperature commercial cooking/frying) could influence the health effects of meat consumption.4 5 
In one study, substitution of one serving per day of other foods (including fish, poultry, nuts, legumes, low-fat dairy, and whole grains) for one serving per day of red meat was associated with a 7% to 19% lower mortality risk.67  A 2015 meta-analysis of prospective cohort studies that reported risk estimates for all-cause, cardiovascular and cancer mortality found an association between processed meat consumption and a 15% increased risk of all-cause and cardiovascular mortality in U.S. populations.8

A 2017 analysis of data from the NIH-AARP study shows an association between high intakes of red and processed meat and elevated all-cause mortality and also elevated mortality from nine different causes including cardiovascular disease, diabetes, cancer, and hepatic, renal, and respiratory diseases.9 

Red and Processed Meat and Cancer

The current consensus, based increasingly on the few prospective studies that are the least susceptible to biases, is that high consumption of red meat and processed meat is associated with an increased risk of colorectal, and possibly pancreatic, prostate and stomach cancers. When meat is processed by smoking or by adding preservatives such as salt or sodium nitrite, the added compounds may be the cause of the increased risk. 

In 2015, the WHO’s International Agency for Research on Cancer (IARC) Monographs Programme classified the consumption of red meat as probably carcinogenic andprocessed meat was classified as carcinogenic to humans, based on sufficient evidencethat the consumption of processed meat causes colorectal cancer.  The IARC concluded that each 50-gram portion of processed meat eaten daily increases the risk of colorectal cancer by 18%.1011  If this small increase in cancer risk is of concern then it is best to avoid bacon, sausage, lunchmeats, hams, hot dogs and other processed meats.

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So what do these studies have to do with children? 
Children who eat a typical American diet show the beginning signs of atherosclerosis early in life.  And food habits are likely to persist into adulthood when the risk of serious illness or death from CVDs is much greater. The 1992 Bogalusa Heart Study found that children who died in accidents already had fatty streaks and plaques on their arteries—the signs of early atherosclerosis.12 In a 1953 study, pathologists examining the coronary arteries of young men (average age 22) who were killed in the Korean War were surprised to find that 77.3% of American soldiers had easily visible evidence of atherosclerosis—and sometimes it was severe.  In contrast, the dead Korean and Chinese soldiers who lived on a plant-based diet were virtually free from atherosclerosis.13 In 1971, similar studies among Vietnam War combat dead, found that 45% of those examined had evidence of coronary atherosclerosis and among 5% the disease was severe.14

Another autopsy study of young people, published in the New England Journal of Medicine in 1998, found that the prevalence of fatty streaks in the coronary arteries increased with age from approximately 50% at age 2 to 15, to 85% at age 21 to 39.  The prevalence of raised fibrous-plaque lesions in the coronary arteries increase from 8% at ages 2 to 15 years to 69% at ages 26 to 39.15

A more recent study among U.S. service men who died from accidental injuries found lower levels of coronary arthrosclerosis.16  While not entirely comparable to the earlier studies, autopsies carried out between 2001 and 2011 found coronary atherosclerosis of any severity among 8.5% of those studied.  It was minimal in 1.5%, moderate in 4.7%, and severe in 2.3%.  The low levels of atherosclerosis may be accounted for by the low levels of risk factors present in this young (average age 27) population compared to the general public.  Only 4% were obese, 3% smoked, 1% had high blood pressure, 0.7% had cholesterol levels higher that 240 mg/dl, and 0.2% had high fasting blood glucose levels.

The 2001-2011 studies of U.S. service men should not be considered a reason for complacency about cardiovascular disease.  A high proportion of the older study subjects showed signs of atherosclerosis.  Those age 40 or older were seven times more likely to have coronary atherosclerosis than those age 24 and younger.  Among those ages 30 to 39 the prevalence of aortic and/or coronary atherosclerosis was 22.1% and among those age 40 or older it was 45.9%.

As shown on the chart below, the progression of cardiovascular disease with advancing age was documented in the National Health and Nutrition Examination Survey that found that the percentage of Americans with cardiovascular disease progressed with age.17


Prevalence of cardiovascular disease in adults ≥20 years of age by age and sex (National Health and Nutrition Examination Survey: 2009-2012). These data include coronary heart disease, heart failure, stroke and hypertension. Source: National Center for Health Statistics and National Heart, Lung, and Blood Institute.

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Cholesterol in the Diet

 According to the 2015-2020 Dietary Guidelines for Americans, “Strong evidence from mostly prospective cohort studies but also randomized controlled trials has shown that eating patterns that include lower intake of dietary cholesterol are associated with reduced risk of CVD, and moderate evidence indicates that these eating patterns are associated with reduced risk of obesity.”18  However, both because dietary cholesterol only weakly influences blood cholesterol levels and because very few Americans consume enough cholesterol to increase their blood levels, the 2015 Dietary Guidelines have dropped the previous advice found in the 2010 edition to limit consumption of dietary cholesterol to 300 mg per day.19
A review of some 40 studies found that high dietary cholesterol statistically significantly increased both serum total cholesterol and LDL-C.20 

 However, dietary cholesterol was not statistically significantly associated with coronary artery disease ischemic stroke or hemorrhagic stroke.  Eggs are a cholesterol rich food.  One large egg contains approximately 186 mg of dietary cholesterol.  Even so, a review of the health effects of egg consumption that considered 30 individual studies, found that many studies showed no association between egg consumption and CVD.21 The authors of one review concluded that the preponderance of evidence suggests that a diet including eggs may be used safely as part of a healthy diet in both the general population and for those at high risk of cardiovascular disease, those with established coronary heart disease, and those with diabetes.22  Other authors have also concluded that egg consumption, although a major source of dietary cholesterol, is not significantly associated with clinical cardiovascular events in the general population.23 
Some nutrition experts recommend continuing attention to dietary cholesterol.24  For example, a study from Korea found that those with high consumption of eggs, 7 eggs per week compared to 0-1 eggs per week, had an 80% increase in the risk of having detectable coronary artery calcification.25  A 2019 study among nearly 30,000 U.S. adults who participated in 6 prospective cohort studies with a median follow-up of 17.5 years, found that each additional 300 mg of dietary cholesterol and each additional half an egg consumed per day were each significantly associated with a small (5%-10%) increase in risk CVD and all-cause mortality.  The study authors concluded that among U.S. adults, higher consumption of dietary cholesterol or eggs was significantly associated with higher risk of CVD and all-cause mortality in a dose-response manner.26

Some epidemiological studies have indicated very little association between a high egg intake and cardiovascular disease or mortality in the general population; however, some sub-groups of the population, notably those with diabetes mellitus, may be at an increased risk from eggs.27 
Current average intake of dietary cholesterol in the United States is approximately 290 mg per day.28  It would appear that although consumption of dietary cholesterol is not a major health risk, avoidance of exceeding 300 mg of cholesterol per day remains the optimal strategy for health. 

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What About Protein––Isn’t More Better?

Because proteins form the body’s muscles and other structures, food advertisers often tout their products as being better for health because they are “high protein.”  The U.S. sales of sports nutrition high protein powders and other products is estimated at $6.6 billion a year. However, very few Americans fail to get enough protein and some of us may get too much.
How much protein do children need? It depends on age, gender, and weight.  The recommended Dietary Allowance (RDA) is that 10% to 30% of calorie intake should come from protein.29 30  Children ages 4 to 13 need about .45 grams of protein for every pound of body weight, that's 3 to 5 ounces—or about 20 to 35 grams—of protein a day.

  • Children ages 4 to 9 need 19 grams of protein each day.
  • Those between ages 9 and 13 need 34 grams.
  • For adolescents, ages 14 to 18, it varies by gender: Boys need 52 grams and girls need 46 grams.

In the U.S. most children get two to three times the protein they need daily, and there is no good evidence that protein bars or powders that provide more than the recommended minimum of about 10%-15% of total calories a day are beneficial.  For teens and young adults this is the equivalent of about 46 grams per day for women and 56 grams for men.  One way to determine an adult’s RDA for protein, is to multiply weight in pounds by 0.36.
An exception to the usual recommendations, that may apply to teenagers, is that to avoid loss of muscle during weight loss, or when weight training to build muscle, and for the elderly, it may be advisable to consume about twice the recommended level.  But consuming 300 grams a day of protein will not help build muscle faster than 100 grams a day.  Although the long-term effects of protein excess are unknown there is concern that it will increase the risk of kidney disease and cancer.31 
Although meat, poultry, and fish provide complete proteins with all of the essential amino acids in them, we don’t need meat or dairy foods for protein: plant foods are a perfectly good source, and probably a preferable source.  Nuts, legumes, seeds, non-fat dairy, and eggs are also excellent protein sources, especially when combined.  Rice, beans, nut butters and whole-grain bread, all have so-called incomplete proteins, but when combined, they balance out what they lack individually in certain amino acids.

A Better Breakfast
What to eat: a diet low in added sugar, saturated and trans fat (mostly phased out of food), and high in natural unrefined whole plant-based foods, (fruits, vegetables, legumes, soy and whole grains).

What to avoid: red meat, foods high in sugar, and many processed foods, because they are likely to be high is sodium, sugar and saturated fat.

Unprocessed and minimally processed breakfast foods can include raw or cooked fruits, vegetables, whole grains like oat meal, and brown rice, and legumes like lentils, beans, chick peas, peanuts and soybeans.

The best food to buy is whole unprocessed and plant-based produce that does not need a Nutrition Facts Label (NFL).  Processed foods are attractive because they have long shelf life, convenience and can be low cost.  By reading the nutrition facts label it is possible to select the healthiest versions of processed breakfast foods:  those high in whole grains, high in fiber and low in sugar, sodium and saturated fat.

Sugars come in many forms.  The ingredients listed on food-product labels that end in “-ose,” such as glucose, sucrose, galactose, dextrose, lactose, fructose or maltose, are sugars. They are healthful components of food when found naturally in milk, fruit and vegetables.  But sugar becomes unhealthy when added in large amounts to foods, most often in the form of sucrose or high-fructose corn syrup.  The NFL provides a listing of total sugar and separately list the amount of the healthy sugars found in fruits and vegetables and the amount of unhealthy added sugars.

Calories per serving: The NFL will list the calories in a serving to reflect the amounts of food people actually eat.  “Low calorie” on the label means 40 or fewer calories per serving, “reduced calorie” means 25% fewer calories than in a same size serving of the original food; and “light or lite” means 33% fewer calories than in a same size serving of the original food.

Fat: “Reduced fat” on the label means at least 25% less fat per serving compared to the original food; “low-fat” signifies 3 grams of fat or less per serving; “fat-free” is 0.5 grams or less fat per serving; and “trans-fat free” signifies 0.5 grams of trans fat or less per serving.

Sodium: “Reduced sodium” means 25% less sodium than in a same size serving of the original food; “light in sodium or lightly salted” signifies 50% less sodium than in a same size serving of the original food. “Low sodium” means 140 mg or less per serving; “very low sodium” means 35 mg or less per serving; and “salt/sodium free” means less than 5 mg sodium per serving.  “No salt added or unsalted” means no salt was added in processing but it does not mean that the product is sodium-free.

Vitamins and minerals: “Excellent source of” means the food has at least 20% of the daily value of that vitamin or mineral per serving: “good source of” means the food has 10-19% of the daily value; “enriched with” lists added vitamins and/or minerals; and “fortified with” signifies adding vitamins and/or minerals that are not in the product naturally.  Consumers should be aware that while it is not likely, it is possible to get too much of a specific dietary supplement from fortified foods.

The healthiest breakfast cereals are 100% whole grain.  They vary markedly in their content of sodium, but many are relatively high in sodium—it is preferable to choose those with under 180 milligrams per serving (sodium can be as high as 400 milligrams per serving).  Sugar content is also highly variable with 0-1 gm. per serving up to 20 gm. per serving––aim for 5 gm. of added sugar or lower.  Be aware that the key health metric is the amount of added sugars, for example, traditional raisin bran is a healthy cereal in spite of high total sugar because the sugar in raisins does not have the unhealthy implications of added sugars, however some added fruit in cereals may be sugar coated so read the label to determine added sugar.  Fiber content is also quite variable from 0 up to 14 gm. per serving––aim for 5 gm or more per serving.

These healthy cereals, that are low in sugar and saturated fat and high in whole grains and fiber, are listed in alphabetical order: All-Bran, Cheerios, Fiber One, GOLEAN (Kashi), Grape Nuts, Shredded Wheat, Total, Wheaties, and Wheat Chex.32  Also keep in mind that although the health effects of dairy foods are still not fully understood, choosing non-fat milk and adding no sugar from the sugar bowl is probably the best way to have your cereal.  When using a soy, almond or any other nondairy beverage, select one that is fortified with calcium and vitamin D and is unsweetened, or at least low in added sugar.33 

Summing up:
Fruit, whole grain breads and cereals like oatmeal and brown rice, carefully selected processed cereals, non-fat yoghurt, vegetables, beans and even an egg (but not two a day) should be on your breakfast menu––skip the bacon, jelly, jam, and sugar filled pastries.

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1 Bernstein AM, Sun Q, Hu FB, Stampfer MJ, Manson JE, Willett WC. Major dietary protein sources and risk of coronary heart disease in women. Circulation. 2010;122:876–883.

2 Larsson SC, Orsini N. Red meat and processed meat consumption and all-cause mortality: a meta-analysis. Am J Epidemiol. 2014; 179: 282-9.

3 Abete I, Romaguera D, Vieira AR et al. (2014) Association between total, processed, red and white meat consumption and all-cause, CVD and IHD mortality: a meta-analysis of cohort studies. Br J Nutr 112, 762–775.

4 Micha R, Wallace S, Mozaffarian D. Red and processed meat consumption and risk of incident coronary heart disease, stroke, and diabetes:a systematic review and meta-analysis. Circulation. 2010;121:2271–2283.

5 Mozaffarian D, Appel LJ, Van Horn L. Components of a Cardioprotective Diet: New Insights. Circulation. 2011;123:2870-2891. DOI: 10.1161/CIRCULATION AHA.110.968735

6 Pan A, Sun Q, Bernstein AM, Schulze MB, Manson JE, Stampfer MJ, Willett WC, Hu FB. Red meat consumption and mortality: results from 2 prospective cohort studies. Arch Intern Med. 2012 Apr 9;172(7):555-63. doi: 10.1001/archinternmed.2011.2287. Epub 2012 Mar 12.

7Ornish D. Holy Cow! What's Good for You Is Good for Our Planet Comment on “Red Meat Consumption and Mortality”. Arch Intern Med. 2012;172(7):563-564. doi:10.1001/archinternmed.2012.174

8Wang X, Lin X, Ouyang YY, Liu J,Zhao G, Pan A, Hu FB. Red and processed meat consumption and mortality: dose-response meta-analysis of prospective cohort studies. Public Health Nutr. 2016 Apr;19(5):893-905. doi: 10.1017/S1368980015002062. Epub 2015 Jul 6.

9 Etemadi A, Sinha R, Ward MH, et al. Mortality from different causes associated with meat, heme iron, nitrates, and nitrites in the NIH-AARP Diet and Health Study: population cohort study. BMJ 2017;357:j1957.

10WHO. Q&A on the carcinogenicity of the consumption of red meat and processed meat. October 2015.  http://www.who.int/features/qa/cancer-red-meat/en/

11WHO, International Agency for Research on Cancer. Press Release No. 240. October 26, 2015. https://www.iarc.fr/en/media-centre/pr/2015/pdfs/pr240_E.pdf

12Berenson GS ed. Bogalusa Heart Study: Evolution of Cardio-metabolic Risk from Childhood to Middle Age. Springer, 2011.

13 Enos WF, Holmes RH, Beyer J. Coronary disease among United States soldiers killed in action in Korea: preliminary report. JAMA. 1953;152(12):1090-1093.

14McNamara JJ, Molot MA, Stremple JF, Cutting RT. Coronary artery disease in combat casualties in Vietnam. JAMA. 1971;216(7):1185-1187.

15Berenson GS, Srinivasan S, Bao W, Newman WP, Tracy RE, Wattigney WA. Association between cardiovascular multiple risk factors and atherosclerosis in children and young adults. N Engl J Med1998;338:1650-6.

16Webber BJ, Seguin PG, Burnett DG, Clark LL, Otto JL. Prevalence of and risk factors for autopsy-determined atherosclerosis among US service members, 2001-2011. JAMA. 2012;308(24):2577-2583.

17Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Despr.s J-P, Fullerton HJ, Howard VJ, Huffman MD, Isasi CR, Jim.nez MC, Judd SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Magid DJ, McGuire DK, Mohler ER III, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Woo D, Yeh RW, Turner MB; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation. 2016;133:e38-e360.

182015-2020 Dietary Guidelines for Americans. https://health.gov/dietaryguidelines/2015/

19Mozaffarian D. Nutrition and cardiovascular disease and metabolic diseases. In: Mann DL, Zipes
DP, Libby P, Bonow RO, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine.
10th ed. Philadelphia, PA: Elsevier/Saunders; 2014.

20 Berger  S, Raman  G, Vishwanathan  R, Jacques  PF, Johnson  EJ.  Dietary cholesterol and cardiovascular disease: a systematic review and meta-analysis.  Am J Clin Nutr. 2015;102(2):276-294.

21Fuller NR, Sainsbury A, Caterson ID, Markovic TP. Egg Consumption and Human Cardio-Metabolic Health in People with and without Diabetes. Nutrients. 2015 Sep 3; 7(9):7399-420. Epub 2015 Sep 3.

22 Fuller NR, Sainsbury A, Caterson ID, Markovic TP. Egg Consumption and Human Cardio-Metabolic Health in People with and without Diabetes. Nutrients. 2015 Sep 3; 7(9):7399-420. Epub 2015 Sep 3..

23 Mozaffarian D, Ludwig DS. Dietary Cholesterol and Blood Cholesterol Concentrations—Reply. JAMA.2015;314(19):2084-2085. doi:10.1001/jama.2015.12604

24 Levin S, Wells C, Barnard N. Dietary Cholesterol and Blood Cholesterol Concentrations. JAMA.2015;314(19):2083-2084. doi:10.1001/jama.2015.12595

25 Choi Y, Chang Y, Lee JE, et al.  Egg consumption and coronary artery calcification in asymptomatic men and women. Atherosclerosis. 2015 Aug;241(2):305-12. doi: 10.1016/j.atherosclerosis.2015.05.036. Epub 2015 Jun 3.

26 Zhong VW, Van Horn L, Cornelis MC, et al. Associations of Dietary Cholesterol or Egg Consumption With Incident Cardiovascular Disease and Mortality. JAMA. 2019;321(11):1081–1095. doi:10.1001/jama.2019.1572

27Fuller NR, Sainsbury A, Caterson ID, Markovic TP. Egg Consumption and Human Cardio-Metabolic Health in People with and without Diabetes. Nutrients. 2015 Sep 3; 7(9):7399-420. Epub 2015 Sep 3.

282015-2020 Dietary Guidelines for Americans. https://health.gov/dietaryguidelines/2015/

31Levine, Morgan E. et al. Low Protein Intake Is Associated with a Major Reduction in IGF-1, Cancer,andOverall Mortality in the 65 and Younger but Not Older Population. Cell Metabolism , Volume 19 , Issue 3 , 407 - 417

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