Advertisement

NOTICE: We are experiencing technical issues with Academy members trying to log into the JAND site using Academy member login credentials. We are working to resolve the issue as soon as possible. Alternatively, if you are an Academy member, you can access the JAND site by registering for an Elsevier account and claiming access using the links at the top of the JAND site. Email us at [email protected] for assistance. Thanks for your patience!

Breakfast in Latin America: Evaluation of Nutrient and Food Group Intake Toward a Nutrient-Based Recommendation

Open AccessPublished:November 16, 2021DOI:https://doi.org/10.1016/j.jand.2021.11.012

      Abstract

      Background

      Little is known about breakfast habits of the Latin American (LA) population to support nutritional recommendations for a balanced breakfast in this region.

      Objective

      To evaluate the nutritional composition of breakfast in the LA population and to propose recommendations for a balanced breakfast.

      Design

      This multicenter cross-sectional study evaluated food and nutrient intake of nationally representative samples of urban populations of 8 LA countries (Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, Peru, and Venezuela) in 2014-2015.

      Participants/setting

      The sample comprised 8714 participants from the Latin American Study of Nutrition and Health, aged 15 to 65 years, randomly recruited according to geographical location, sex, age, and socioeconomic level.

      Main outcome measures

      Two 24-hour recalls were used to examine dietary intake. Breakfast consumers were stratified by tertiles of Nutrient-Rich Foods Index 9.3 (NRF9.3) to assess the overall diet quality of individuals. Nutrient intake at breakfast of those in the upper tertile of NRF9.3 pooled for the 8 countries was used as a reference for the development of recommendations for LA adolescents and adults.

      Statistical analyses

      Comparison of food and nutrient intake of breakfast across NRF9.3 tertiles were analyzed using the Kruskal-Wallis rank sum test.

      Results

      Overall breakfast was an important contributor to protein, carbohydrate, and B vitamin intakes but also to added sugar and total and saturated fat intakes relative to daily intakes. Individuals in the upper NRF9.3 tertile had higher intake of key micronutrients such as calcium and potassium at breakfast compared with other tertiles. White breads/rolls/tortillas were the most consumed food group (60%), followed by butter/margarine (40%) and coffee/tea without milk (34%-50%).

      Conclusions

      Breakfast contributed to the daily intake of B vitamins, protein, and carbohydrates but also added sugar and total and saturated fat intakes for all countries. The proposed recommendations support the nutrient density of existing highest-quality breakfast in the LA population while addressing concerns about nutrients to be encouraged or reduced.

      Keywords

      Research Question: What is the nutritional composition of breakfast in Latin American (LA) populations and what recommendations can be proposed for a balanced breakfast in this group?
      Key Findings: This multicenter cross-sectional study of the nutritional intake of 8 LA countries shows that breakfast is a nutrient-rich eating occasion relative to daily energy intake. Although breakfast is an important contributor to B vitamins, protein, and carbohydrate intakes, it is also a source of added sugar and total and saturated fat. Breakfast intake of those individuals with the best daily diet quality, along with the current international dietary guidelines, were used to develop nutrient-based recommendations for a balanced breakfast for the first time in LA.
      Eating habits, including number and quality of daily meals, have shown to be an important contributor to people’s health.
      • Micha R.
      • Penalvo J.L.
      • Cudhea F.
      • Imamura F.
      • Rehm C.D.
      • Mozaffarian D.
      Association between dietary factors and mortality from heart disease, stroke, and type 2 diabetes in the United States.
      More than any other meal, the nutritional composition of breakfast has received special attention in the literature in the last years.
      • Sievert K.
      • Hussain S.M.
      • Page M.J.
      • et al.
      Effect of breakfast on weight and energy intake: Systematic review and meta-analysis of randomised controlled trials.
      Although energy contribution of this meal might be smaller in comparison with other main meals, findings from cross-sectional and interventional studies have reported that eating breakfast may be a predictor of healthy eating behavior.
      • Haire-Joshu D.
      • Schwarz C.
      • Budd E.
      • Yount B.W.
      • Lapka C.
      Postpartum teens’ breakfast consumption is associated with snack and beverage intake and body mass index.
      • Navarro-Gonzalez I.
      • Ros G.
      • Martinez-Garcia B.
      • Rodriguez-Tadeo A.
      • Periago M.J.
      Adherencia a la dieta mediterránea y su relación con la calidad del desayuno en estudiantes de la Universidad de Murcia.
      • Delley M.
      • Brunner T.A.
      Breakfast eating patterns and drivers of a healthy breakfast composition.
      • Rampersaud G.C.
      • Pereira M.A.
      • Girard B.L.
      • Adams J.
      • Metzl J.D.
      Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents.
      Regular breakfast consumption has been associated with higher consumption of fruits, vegetables, milk, and grains and fewer total calories from snacks and beverages compared with breakfast skipping,
      • Haire-Joshu D.
      • Schwarz C.
      • Budd E.
      • Yount B.W.
      • Lapka C.
      Postpartum teens’ breakfast consumption is associated with snack and beverage intake and body mass index.
      and consequently, it has been associated with higher intake of micronutrients and higher odds of meeting nutritional recommendations.
      • Rampersaud G.C.
      • Pereira M.A.
      • Girard B.L.
      • Adams J.
      • Metzl J.D.
      Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents.
      Despite its potential importance, there are no established food group or nutrient criteria for an ideal composition of breakfast, that could be applicable broadly across Latin America (LA). The Dietary Guidelines for the Brazilian and Argentinian populations
      Brasil, Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica
      ,
      • Ministerio de Salud de la Nacion.
      do not recommend amounts of foods or nutrients specifically for breakfast; however, they give examples of quality breakfast according to each country’s habits and recommend the consumption of natural or minimally processed foods, such as fruits, coffee, and milk, and culinary preparations based on grains or tubers, such as cassava. The International Breakfast Research Initiative (IBRI) developed quantitative breakfast recommendations for achieving a balanced breakfast, that is, a nutritionally adequate breakfast, considering the existing distinctive and cultural eating habits of the population.
      • Gibney M.J.
      • Barr S.I.
      • Bellisle F.
      • et al.
      Towards an evidence-based recommendation for a balanced breakfast-a proposal from the International Breakfast Research Initiative.
      Data from nationally representative dietary intake databases from 6 Western European and North American countries were analyzed taking both reported breakfast and daily nutrient intakes into account. These recommendations were developed using a new approach based on nutrient intakes of breakfasts that were associated with the highest overall daily dietary quality and allowed for local adaptation.
      A previous study in LA reported that the majority of participants were regular breakfast consumers (who consumed breakfast on both 24-hour dietary recalls [24HRs]) and that breakfast skipping was more frequent among adolescents.
      • Fisberg M.
      • Kovalskys I.
      • Previdelli A.N.
      • et al.
      Breakfast consumption habit and its nutritional contribution in Latin America: Results from the ELANS Study.
      The study found that in most countries breakfast was a meal with a higher content of carbohydrates, added sugars, saturated fat, and calcium and lower content of protein and fats relative to the entire day. A more detailed evaluation of the nutritional composition of breakfast could contribute to the development of data-driven nutrient recommendations for this meal in LA, considering both daily nutrient and breakfast intakes. Thus, the objective of this study was to evaluate nutrient and food group intakes at breakfast in LA and to propose nutrient-based recommendations for a balanced breakfast for adolescents and adults according to breakfast intake of the population with the highest daily diet quality.

      Participants and Methods

      Study Sample

      This study was based on the data derived from the Latin American Study of Nutrition and Health (ELANS), a multicenter cross-sectional survey originally designed to collect information on food and nutrient intake, nutritional status, and physical activity levels of nationally representative samples of urban populations of 8 LA countries (Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, Peru, and Venezuela). The complete methodology of the study has been described in detail elsewhere.
      • Fisberg M.
      • Kovalskys I.
      • Gomez G.
      • et al.
      Latin American Study of Nutrition and Health (ELANS): Rationale and study design.
      In brief, sample participants aged 15 to 65 years old were randomly recruited by multistage sampling method stratified by geographical location (only urban areas), sex, age, and socioeconomic level (SEL). Participants were evaluated on 2 household visits on nonconsecutive days (with an interval of up to 8 days between them) over 1 year (from September 2014 to August 2015). The following exclusion criteria were applied: (a) pregnant and lactating women; (b) persons with physical or mental disabilities; (c) unsigned consent form; (d) individuals living in nonfamily residential environments; and (e) individuals who could not read. The total eligible sample from the ELANS was composed of 9218 subjects; however, this study final sample consisted of 8714 individuals, as described in detail in the “Dietary Assessment” section.
      The overarching ELANS protocol was approved by the Western Institutional Review Board (#20140605) and is registered at Clinical Trials (#NCT02226627). Each site-specific protocol was also approved by the ethical review boards of the participating institutions. All study sites adhered to a common study protocol for interviewer training, implementation of fieldwork, data collection and management, and quality control procedures. All participants gave their informed consent/assent before participation in the survey.

      Sociodemographic Data

      Questionnaires administered by trained interviewers at the participants’ households were used to collect information about demographics (such as sex and age) and SEL. Participants were categorized into 2 age groups: adolescents (15-19 years, n = 1140) and adults (20-65 years, n = 7574). SEL questionnaires used a country-dependent format based on the national indexes used in each country. SEL data were divided into 3 strata (low, medium, and high) based on the national indexes used in each country.
      • Fisberg M.
      • Kovalskys I.
      • Gomez G.
      • et al.
      Latin American Study of Nutrition and Health (ELANS): Rationale and study design.

      Dietary Assessment

      Dietary data were obtained using 2 nonconsecutive 24HRs collected at 2 household visits. The Multiple Pass Method
      • Moshfegh A.J.
      • Rhodes D.G.
      • Baer D.J.
      • et al.
      The US Department of Agriculture Automated Multiple-Pass Method reduces bias in the collection of energy intakes.
      approach was used to provide detailed information of all food and beverages, including water and alcoholic beverages, and preparations/recipes consumed over the 24 hours before the interview in household measures. Data collected were analyzed through the Nutrition Data System for Research software, versions 2013

      Nutrition Data System for Research. Version 2013. Nutrition Coordinating Center; 2013.

      (for Argentina, Chile, Costa Rica, Ecuador, and Venezuela) and 2014

      Nutrition Data System for Research. Version 2014. Nutrition Coordinating Center; 2014.

      (for Brazil, Colombia, and Peru) (NDS-R, Minnesota University). Before entering data on the NSDS-R software, professional nutritionists in each country followed a standardization procedure for matching the nutritional equivalency of local foods to foods available in the US Department of Agriculture food composition table in the NDS-R database. The complete procedure for standardization of the food composition database has been described in detail elsewhere.
      • Kovalskys I.
      • Fisberg M.
      • Gomez G.
      • et al.
      Standardization of the food composition database used in the Latin American Nutrition and Health Study (ELANS).
      Breakfast was defined by self-report and included consumption of any food or beverage at a meal occasion named by the respondent as breakfast. The total ELANS sample was considered for the current study, therefore 18,436 24HRs (ie, 9218 individuals × two 24HRs = 18,436) were assessed. The following exclusion criteria were then applied: breakfast skippers (n = 504), who did not consume breakfast intentionally or not intentionally on both days; breakfasts with less than 50 kcal
      • De Castro J.M.
      Methodology, correlational analysis, and interpretation of diet diary records of the food and fluid intake of free-living humans.
      (731 24HRs); breakfasts derived exclusively from alcoholic beverages (six 24HRs); and inconsistent data (one 24HR, typing error). The final sample comprised 8714 breakfast consumers (individuals who had breakfast in one or both 24HRs, for a total of 15,961 24HRs). The complete methodology of the final sample was described elsewhere.
      • Fisberg M.
      • Kovalskys I.
      • Previdelli A.N.
      • et al.
      Breakfast consumption habit and its nutritional contribution in Latin America: Results from the ELANS Study.
      For the purpose of the present study, only data of breakfast consumers were used in the analysis.

      Measures of Diet Quality

      The Nutrient-Rich Foods Index 9.3 (NRF9.3),
      • Fulgoni 3rd, V.L.
      • Keast D.R.
      • Drewnowski A.
      Development and validation of the nutrient-rich foods index: A tool to measure nutritional quality of foods.
      a validated nutrient profiling method used previously in the IBRI studies,
      • Gibney M.J.
      • Barr S.I.
      • Bellisle F.
      • et al.
      Breakfast in human nutrition: The International Breakfast Research Initiative.
      was applied to assess the overall diet quality score of the breakfast consumers of each LA country. Because breakfast has been shown to significantly contribute to the daily micronutrient intake, the NRF9.3 was chosen, due to the positive influence of micronutrients to the scoring system.
      • Gibney M.J.
      • Barr S.I.
      • Bellisle F.
      • et al.
      Towards an evidence-based recommendation for a balanced breakfast-a proposal from the International Breakfast Research Initiative.
      ,
      • Fisberg M.
      • Kovalskys I.
      • Previdelli A.N.
      • et al.
      Breakfast consumption habit and its nutritional contribution in Latin America: Results from the ELANS Study.
      The NRF9.3 variation used for the IBRI studies
      • Gibney M.J.
      • Barr S.I.
      • Bellisle F.
      • et al.
      Breakfast in human nutrition: The International Breakfast Research Initiative.
      is based on the sum of daily intakes of 9 “nutrients to encourage” (protein; fiber; vitamins A, C, and D; calcium; iron; magnesium; and potassium) expressed as percentages of Daily Reference Values (DRVs) normalized to an intake of 2000 kcal, minus the sum of the percentage of the maximum recommended values for 3 “nutrients to limit” (added sugar, saturated fat, and sodium). Vitamin E was replaced by vitamin D in the list of the 9 “nutrients to encourage.” The NRF9.3 algorithm is represented below:
      NRF9.3=(i=19Intakei/Energy×2000DRVij=13Intakej/Energy×2000MRVj1)×100


      where Intakei or Intakej is the intake of each nutrient i to encourage or j to limit, Energy represents daily energy intake, DRVi is the DRV for nutrients i, and MRVj is the maximum reference value for nutrients j.
      • Fulgoni 3rd, V.L.
      • Keast D.R.
      • Drewnowski A.
      Development and validation of the nutrient-rich foods index: A tool to measure nutritional quality of foods.
      Percentage DRVs for “nutrients to encourage” were capped at 100; that is, in this case the nutrient scores (subscores) were truncated at 1, so that high intake of 1 nutrient could not compensate for the dietary inadequacy of another.
      • Fulgoni 3rd, V.L.
      • Keast D.R.
      • Drewnowski A.
      Development and validation of the nutrient-rich foods index: A tool to measure nutritional quality of foods.
      As for “nutrients to limit,” if the Intakei was less than 1, then 0 was assigned to the score of that nutrient. In all other cases, 1 was subtracted from the score. The maximum possible total score was 900, where intakes/2000 kcal for all 9 nutrients to encourage was above DRV, and intakes of all 3 nutrients to limit were below DRV.
      • Fulgoni 3rd, V.L.
      • Keast D.R.
      • Drewnowski A.
      Development and validation of the nutrient-rich foods index: A tool to measure nutritional quality of foods.
      The DRVs were based on the dietary reference intakes published by the Institute of Medicine,
      • Trumbo P.
      • Schlicker S.
      • Yates A.A.
      • Poos M.
      Food, Nutrition Board of the Institute of Medicine TNA
      Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein and amino acids.
      ,
      • Trumbo P.
      • Yates A.A.
      • Schlicker S.
      • Poos M.
      Dietary reference intakes: Vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc.
      Food and Agriculture Organization,
      FAO
      Fats and Fatty Acids in Human Nutrition. Report of an Expert Consultation.
      World Health Organization,
      WHO
      Global Action Plan for the Prevention and Control of NCDs 2013–2020.
      WHO
      Guideline: Potassium intake for adults and children. World Health Organization.
      WHO
      Guideline: Sugars Intake for Adults and Children.
      European Union Regulation,
      European Parliament
      European Council Regulation (EU) No. 1169/2011 of the European Parliament and of the Council of 25 October 2011 on the provision of food information to consumers.
      and other IBRI studies.
      • Barr S.I.
      • Vatanparast H.
      • Smith J.
      Breakfast in Canada: Prevalence of consumption, contribution to nutrient and food group intakes, and variability across tertiles of daily diet quality. A study from the International Breakfast Research Initiative.
      • Bellisle F.
      • Hebel P.
      • Salmon-Legagneur A.
      • Vieux F.
      Breakfast consumption in French children, adolescents, and adults: A nationally representative cross-sectional survey examined in the context of the International Breakfast Research Initiative.
      • Drewnowski A.
      • Rehm C.D.
      • Vieux F.
      Breakfast in the United States: Food and nutrient intakes in relation to diet quality in National Health and Examination Survey 2011-2014. A study from the International Breakfast Research Initiative.
      • Fagt S.
      • Matthiessen J.
      • Thyregod C.
      • Korup K.
      • Biltoft-Jensen A.
      Breakfast in Denmark. Prevalence of consumption, intake of foods, nutrients and dietary quality. A study from the International Breakfast Research Initiative.
      • Gaal S.
      • Kerr M.A.
      • Ward M.
      • McNulty H.
      • Livingstone M.B.E.
      Breakfast consumption in the UK: Patterns, nutrient intake and diet quality. A study from the International Breakfast Research Initiative Group.
      • Ruiz E.
      • Avila J.M.
      • Valero T.
      • Rodriguez P.
      • Varela-Moreiras G.
      Breakfast consumption in Spain: Patterns, nutrient intake and quality. Findings from the ANIBES Study, a study from the International Breakfast Research Initiative.
      The DRVs used to calculate the NRF9.3 were as follows: (1) “nutrients to encourage”: protein 50 g, vitamin A 900 mg, vitamin C 90 mg, calcium 1300 mg, iron 18 mg, magnesium 420 mg, potassium 4700 mg, fiber 25 g, and vitamin D 5 μg; and (2) “nutrients to limit”: sodium 2300 mg, saturated fat 10% of the Total Energy Intake (TEI), and added sugar 10%TEI. DRVs for “nutrients to limit” were based on maximum recommended values.
      The NRF9.3 tertiles were calculated separately for each country and then compiled as a single database to allow for comparisons across countries. NRF9.3 was stratified by tertiles for each age group across all countries: adolescents (n = 1140) and adults (n = 7574). The lower tertile (T1) was indicative of the lowest level of overall daily diet quality, and the upper tertile (T3) represented the highest overall daily diet quality. The nutrient intakes at breakfast for those at the upper tertile were used as reference for the development of recommendations for the LA region, focusing on setting attainable quantitative recommendations that could improve total daily diet quality.
      • Gibney M.J.
      • Barr S.I.
      • Bellisle F.
      • et al.
      Towards an evidence-based recommendation for a balanced breakfast-a proposal from the International Breakfast Research Initiative.

      Principles for the Development of Nutrient Recommendation for Breakfast

      The average nutrient intakes of breakfast in the population with the highest-quality diets were compared with recommended daily intakes from the Institute of Medicine,
      • Trumbo P.
      • Schlicker S.
      • Yates A.A.
      • Poos M.
      Food, Nutrition Board of the Institute of Medicine TNA
      Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein and amino acids.
      ,
      • Trumbo P.
      • Yates A.A.
      • Schlicker S.
      • Poos M.
      Dietary reference intakes: Vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc.
      Food and Agriculture Organization,
      FAO
      Fats and Fatty Acids in Human Nutrition. Report of an Expert Consultation.
      and World Health Organization.
      WHO
      Global Action Plan for the Prevention and Control of NCDs 2013–2020.
      WHO
      Guideline: Potassium intake for adults and children. World Health Organization.
      WHO
      Guideline: Sugars Intake for Adults and Children.
      By using 5 key guiding principles adapted from IBRI
      • Gibney M.J.
      • Barr S.I.
      • Bellisle F.
      • et al.
      Towards an evidence-based recommendation for a balanced breakfast-a proposal from the International Breakfast Research Initiative.
      and based on the comparison between the intakes observed and the daily recommendations, nutrient recommendations were proposed for the breakfast of the LA population, as follows.

      Principle 1

      The first principle is based on the contribution of breakfast to daily energy intake, according to age group. As a result, a value closer to the midpoint of the observed range of energy intakes is proposed as a benchmark for setting the percentage of energy (%) and nutrient recommendations, based on a 2000 kcal diet.

      Principle 2

      For nutrients in which there is evidence that the median daily population intake is higher than DRV among most countries (data not shown), the target was set to the lower range of the median national values found in the upper NRF9.3 tertile.

      Principle 3

      For nutrients where (1) the median population intakes are close to optimal relative to the reference values, and (2) breakfast contributes significantly to daily intakes (more than the percentage found in the principle 1), the target is set to the average intakes range from individuals in the upper NRF9.3 tertile.

      Principle 4

      Where the median population intakes are generally less than the reference values and there is wide variation in breakfast contribution across countries, the target will be based on the value of the country with the highest percentage of contribution. If this value exceeds the energy intake of breakfast, then the same percentage of energy, proposed on the principle 1, will be considered.

      Principle 5

      For macronutrients to limit, the proposal is to adopt the World Health Organization guideline values expressed as percentage of breakfast energy intake.
      The main difference from IBRI
      • Gibney M.J.
      • Barr S.I.
      • Bellisle F.
      • et al.
      Towards an evidence-based recommendation for a balanced breakfast-a proposal from the International Breakfast Research Initiative.
      principles is that the present analyses were based on median values, instead of mean values, since the distribution of most variables was asymmetric. Also, the fourth principle was based on intakes from the country with the highest percentage of contribution, instead of the Codex.

      Food Grouping

      An adapted version of the What We Eat in America Food Classification System was used to classify the foods and beverages consumed by the study population. Nine of the 15 main groups of the What We Eat in America Food Classification System were evaluated in this study: milk and dairy, protein foods, grains, snacks and sweets, fruit, vegetables, nonalcoholic beverages, fats and oils, and sugars. From these 9 main groups, 27 food subgroups most frequently consumed by the total population (eg, whole grain bread, rolls, and tortillas; white bread, rolls, and tortillas; plain and flavored whole milk; plain and flavored nonfat, low-fat, or reduced-fat milk; butter and margarine; cheese) were included to calculate the percentage contribution of food groups to key nutrient intakes at breakfast. The same 27 food subgroups were compared across diet quality tertiles in adolescents and adults.

      Statistical Analysis

      The Kolmogorov-Smirnov test was applied to check the distribution of the data. Descriptive statistics were primarily reported as means and SD and/or in percentages. Associations between NRF9.3 tertiles and demographic characteristics (sex, age, SEL, and country) were tested using χ2 tests by each age group (adolescents or adults). Comparison of LA breakfast energy, macro- and micronutrients, and food groups intakes (grams) across tertiles of the daily NRF9.3 were carried out by the nonparametric post hoc multiple comparisons of Kruskal-Wallis rank sum test for each age group. Nutrient-based recommendations for a balanced breakfast were developed using pooled data of 8 LA countries. All analyses were performed with SPSS version 22 software.

      IBM SPSS Statistics for Windows. Version 22. IBM Corp; 2013.

      The statistical significance level was set at P < .05.

      Results

      Table 1 shows descriptive characteristics of the ELANS breakfast consumers according to NRF9.3 tertile, age group, sex, and SEL. Sex, age, and SEL were significantly different between tertiles of daily diet quality in adults (P < .05), although only sex was significantly different between NRF9.3 tertiles in adolescents (P < .001). Among adolescents, those with higher daily diet quality were more likely to be girls. Among adults, those with higher daily diet quality were more likely to be women, older (50-65 years old), and high SEL. No significant differences were found in NRF9.3 between countries, which confirms that tertiles were evenly distributed among each country.
      Table 1Descriptive characteristics of the 8714 breakfast consumers according to mean daily diet quality
      Mean daily diet quality was calculated from the average of 2 nonconsecutive 24-hour dietary recalls (24HRs), for individuals who had breakfast in both 24HRs, and one 24HR, for individuals with breakfast in only one 24HR.
      determined by NRF9.3
      NRF9.3 = Nutrient-Rich Foods Index 9.3.
      tertiles, from the 2014-2015 ELANS
      ELANS = Latin American Study of Nutrition and Health.
      study
      CharacteristicsNRF9.3 Tertiles
      NRF9.3 score was calculated separately to divide the study participants into tertiles per country. NRF9.3 tertile score ranges for each age group were adolescents: tertile 1, 163-603; tertile 2, 345-649; tertile 3, 412-824; and adults: tertile 1, −36-647; tertile 2, 393-699; tertile 3, 479-856.
      Adolescents (15-19 y; n = 1140)
      P value
      Pearson χ2 test; statistically significant difference indicated by P < .05.
      NRF9.3 Tertiles
      NRF9.3 score was calculated separately to divide the study participants into tertiles per country. NRF9.3 tertile score ranges for each age group were adolescents: tertile 1, 163-603; tertile 2, 345-649; tertile 3, 412-824; and adults: tertile 1, −36-647; tertile 2, 393-699; tertile 3, 479-856.
      Adults (20-65 y; n = 7574)
      P value
      Pearson χ2 test; statistically significant difference indicated by P < .05.
      TotalT1T2T3TotalT1T2T3
      n (%)n (%)
      Sex
      Male638241 (38)227 (36)170 (27)<.00135331577 (45)1207 (34)749 (21)<.001
      Female502142 (28)152 (30)208 (41)4041950 (24)1318 (33)1773 (44)
      Age group (y)
      15-191140383 (34)379 (33)378 (33)
      20-3432901542 (47)1122 (34)626 (19)<.001
      35-492484726 (29)909 (37)849 (34)
      50-651800259 (14)494 (27)1047 (58)
      Socioeconomic level
      High10637 (35)37 (35)32 (30).462738205 (28)254 (34)279 (38).006
      Medium436141 (32)136 (31)159 (36)2912966 (33)971 (33)975 (33)
      Low598205 (34)206 (34)187 (31)39241356 (35)1300 (33)1268 (32)
      Country
      Argentina12642 (33)42 (33)42 (33).9991005335 (33)335 (33)335 (33).999
      Brazil20468 (33)68 (33)68 (33)1595532 (33)532 (33)531 (33)
      Chile11238 (34)37 (33)37 (33)728243 (33)243 (33)242 (33)
      Peru16355 (34)54 (33)54 (33)936312 (33)312 (33)312 (33)
      Colombia14549 (34)48 (33)48 (33)1051351 (33)350 (33)350 (33)
      Costa Rica11639 (34)39 (34)38 (33)657219 (33)219 (33)219 (33)
      Ecuador12642 (33)42 (33)42 (33)658220 (33)219 (33)219 (33)
      Venezuela14850 (34)49 (33)49 (33)944315 (33)315 (33)314 (33)
      a Mean daily diet quality was calculated from the average of 2 nonconsecutive 24-hour dietary recalls (24HRs), for individuals who had breakfast in both 24HRs, and one 24HR, for individuals with breakfast in only one 24HR.
      b NRF9.3 = Nutrient-Rich Foods Index 9.3.
      c ELANS = Latin American Study of Nutrition and Health.
      d NRF9.3 score was calculated separately to divide the study participants into tertiles per country. NRF9.3 tertile score ranges for each age group were adolescents: tertile 1, 163-603; tertile 2, 345-649; tertile 3, 412-824; and adults: tertile 1, −36-647; tertile 2, 393-699; tertile 3, 479-856.
      e Pearson χ2 test; statistically significant difference indicated by P < .05.

      Nutrient Intakes at Breakfast by Daily Diet Quality

      Breakfast provided overall about 498 kcal in adolescents and 436 kcal in adults (Table 2, available at www.jandonline.org). The intake of most nutrients varied across NRF9.3 tertiles in the expected direction (ie, nutrients to encourage were highervitamins A and D, calcium, and potassium for adolescents and fiber, calcium, and potassium for adults) and nutrients to limit were lower (added sugar, saturated fat, and sodium for both groups) in those of tertile 3 compared with tertile 1. Energy content, carbohydrate, and total and saturated fat were higher in tertile 1 compared with tertile 3 for both age groups, and protein, thiamine, riboflavin, niacin, and iron were higher in tertile 1 compared with tertile 3 in the adults group.
      Tables 3 and 4 show the nutritional intake of NRF9.3 tertile 3 at breakfast and the contribution of these intakes to the daily requirement values among adolescents and adults by country, respectively. Overall, breakfast was an important contributor (>20% DRV) to the intakes of protein and vitamin B complex (except B6) and low contributor (<10% DRV) to the intakes of vitamin C and potassium. Breakfast was also an important contributor to the intake of carbohydrate, added sugar, total fat, and saturated fat as those nutrients’ intakes were very similar to the daily recommendations.
      Table 3Nutritional intakes at breakfast by country among the 378 adolescents of the upper NFR 9.3
      NRF9.3 = Nutrient-Rich Foods Index 9.3.
      tertile who participated in the 2014-2015 ELANS
      ELANS = Latin American Study of Nutrition and Health.
      study
      Nutrient intakes and NRF9.3 score were calculated from the average of 2 nonconsecutive 24-hour dietary recalls (24HRs), for individuals who had breakfast in both 24HRs, and one 24HR, for individuals with breakfast in only one 24HR.
      NutrientsELANS (n = 378)Argentina (n = 42)Brazil (n = 68)Chile (n = 37)Colombia (n = 48)Costa Rica (n = 38)Ecuador (n = 42)Peru (n = 54)Venezuela (n = 49)DRV
      DRV = Daily Reference Value.
      median (% DRV)
      Energy (kcal)410 (−)284 (−)383 (−)349 (−)502 (−)366 (−)439 (−)413 (−)452 (−)
      Protein (g)13.4 (26.8)9.1 (18.2)12.4 (24.9)13 (26)19.1 (38.2)9.7 (19.4)15.5 (31)13.9 (27.7)15.2 (30.5)50 g
      Carbohydrate (g)
      Expressed as percentage of breakfast energy. The other nutrients are expressed as percent of DRV.
      56.9 (55.3)49.6 (65.6)52.1 (54.2)46.4 (53.2)63.4 (53.3)56.2 (58.4)62.7 (55.5)64 (62.4)57.5 (47.9)55%-75% TEI
      TEI = total energy intake.
      Added sugar (g)
      Expressed as percentage of breakfast energy. The other nutrients are expressed as percent of DRV.
      11.7 (10)14.6 (20.7)7.2 (7.9)4.8 (5.4)10.8 (7.9)10.3 (10.8)15.5 (12.6)11.6 (11.8)15 (10.3)<10% TEI
      Total fat (g)
      Expressed as percentage of breakfast energy. The other nutrients are expressed as percent of DRV.
      12.1 (28)6.1 (19.7)12.9 (31)10.5 (30.2)18.5 (29.2)10.7 (26.5)14.3 (30.4)9.2 (22.3)18.2 (36.1)<30% TEI
      Saturated fat (g)
      Expressed as percentage of breakfast energy. The other nutrients are expressed as percent of DRV.
      4.7 (10.5)3.1 (8.7)5.4 (10.6)4.9 (13.8)7.2 (12)3.1 (8.3)6.5 (12.8)2.7 (6.4)5.9 (10.5)<10% TEI
      Fiber (g)2.9 (11.6)1.6 (6.5)2.3 (9.2)2.4 (9.5)3.5 (13.9)3.6 (14.3)2.9 (11.4)3.4 (13.6)3.6 (14.2)25 g
      Vitamin A (mg)125.8 (14)65.6 (7.3)83.9 (9.3)132.6 (14.7)175.8 (19.5)132.5 (14.7)153.1 (17)137.5 (15.3)120.2 (13.4)900 mg
      Thiamin (mg)0.4 (33.4)0.3 (27.1)0.3 (28)0.3 (28.4)0.5 (43.1)0.4 (31.3)0.4 (31.6)0.4 (29.7)0.6 (51.7)1.2 mg
      Riboflavin (mg)0.5 (41.6)0.4 (34)0.5 (40.1)0.5 (41.8)0.8 (65.3)0.4 (33)0.5 (42.1)0.4 (33.3)0.5 (44.9)1.2 mg
      Niacin (mg)3.7 (24.4)2.8 (18.8)2.9 (19.5)3.1 (20.9)5 (33.3)3.3 (22.1)4.3 (28.9)3.6 (24.2)5 (33.6)15 mg
      Vitamin B6 (mg)0.2 (16.9)0.1 (8.7)0.1 (11.4)0.2 (15.5)0.3 (25.5)0.2 (14.8)0.3 (21.8)0.2 (14.9)0.3 (24.8)1.3 mg
      Vitamin B12 (μg)0.8 (31.8)0.6 (25.8)0.7 (28.8)1.1 (44.1)1.4 (59.5)0.7 (27.4)1.2 (50.8)0.3 (11.7)0.8 (31.6)2.4 μg
      Vitamin C (mg)4.2 (4.7)0.7 (0.7)1.9 (2.1)2.5 (2.8)5.6 (6.3)5.4 (6)10.8 (12)7.1 (7.9)5.6 (6.2)90 mg
      Vitamin D (μg)1 (19.6)0.6 (11.2)0.1 (1.9)2.1 (41.6)2.7 (53.8)0.6 (12.1)2.4 (47)0.6 (12.7)0.6 (12.5)5 μg
      Calcium (mg)215.5 (16.6)155.5 (12)206.3 (15.9)254.4 (19.6)338.7 (26.1)85.5 (6.6)343.3 (26.4)116.7 (9)231.1 (17.8)1300 mg
      Iron (mg)2.8 (15.5)2.3 (12.7)2.4 (13.2)2.5 (13.9)3.6 (20.3)2.8 (15.7)2.7 (14.9)3.3 (18.1)3.1 (17.3)18 mg
      Potassium (mg)427.3 (9.1)233.9 (5)371.9 (7.9)427 (9.1)695.1 (14.8)429.1 (9.1)503.9 (10.7)373.2 (7.9)419.1 (8.9)4700 mg
      Magnesium (mg)49.7 (11.8)29.3 (7)38.4 (9.1)43.3 (10.3)71.8 (17.1)44.1 (10.5)57.6 (13.7)55.1 (13.1)62.3 (14.8)420 mg
      Zinc (mg)1.8 (16.2)1.9 (17.2)1.4 (12.7)1.5 (13.7)2.4 (21.9)1.5 (13.6)1.9 (17.1)1.7 (15.4)2.2 (20.3)11 mg
      Sodium (mg)469.6 (20.4)368.3 (16)504.5 (21.9)450.6 (19.6)450.6 (19.6)427.7 (18.6)584.3 (25.4)295.9 (12.9)796.1 (34.6)2300 mg
      Mean NRF9.3 score574.4441.2523.7595.4681.6554.9578.5651.5565.9
      a NRF9.3 = Nutrient-Rich Foods Index 9.3.
      b ELANS = Latin American Study of Nutrition and Health.
      c Nutrient intakes and NRF9.3 score were calculated from the average of 2 nonconsecutive 24-hour dietary recalls (24HRs), for individuals who had breakfast in both 24HRs, and one 24HR, for individuals with breakfast in only one 24HR.
      d DRV = Daily Reference Value.
      e Expressed as percentage of breakfast energy. The other nutrients are expressed as percent of DRV.
      f TEI = total energy intake.
      Table 4Nutritional intakes at breakfast by country among the 2522 adults of the upper tertile of the NFR 9.3
      NRF9.3 = Nutrient-Rich Foods Index 9.3.
      who participated in the 2014-2015 ELANS
      ELANS = Latin American Study of Nutrition and Health.
      study
      Nutrient intakes and NRF9.3 score were calculated from the average of 2 nonconsecutive 24-hour dietary recalls (24HRs), for individuals who had breakfast in both 24HRs, and one 24HR, for individuals with breakfast in only one 24HR.
      NutrientsELANS (n = 2522)Argentina (n = 335)Brazil (n = 531)Chile (n = 242)Colombia (n = 312)Costa Rica (n = 350)Ecuador (n = 219)Peru (n = 219)Venezuela (n = 314)DRV
      DRV = Daily Reference Value.
      median (% DRV)
      Energy (kcal)325 (−)207 (−)298 (−)293 (−)425 (−)280 (−)410 (−)355 (−)395 (−)
      Protein (g)11.3 (22.6)6.9 (13.8)9.4 (18.7)10.6 (21.1)16.5 (33.1)9.5 (19.1)14.7 (29.4)13 (26)13.8 (27.7)50 g
      Carbohydrate (g)
      Expressed as percentage of breakfast energy.
      47.9 (55.3)42.3 (65.4)43.5 (55.4)43.2 (57.3)56 (51)41.7 (55.1)54.9 (51.8)55.9 (57.1)50 (49.6)55%-75% TEI
      TEI = total energy intake.
      Added sugar (g)
      Expressed as percentage of breakfast energy.
      8.2 (9.5)6.7 (11.3)6.6 (8.5)3.9 (5)8.7 (8.4)6.8 (9.8)10.6 (10)10.7 (11.2)10.6 (10.1)<10% TEI
      Total fat (g)
      Expressed as percentage of breakfast energy.
      10.1 (28.1)4.4 (19.1)9.3 (29.3)8.1 (25.5)14.5 (31)9.5 (28.1)14.3 (32.1)10.3 (25.1)14 (33.4)<30% TEI
      Saturated fat (g)
      Expressed as percentage of breakfast energy.
      3.6 (9.9)1.6 (6.6)3.4 (10.2)3.5 (10.4)5.9 (12.3)2.7 (8.4)5 (10.7)3.1 (7.6)4.8 (11.5)<10% TEI
      Fiber (g)2.7 (10.7)1.3 (5.4)2.2 (8.7)2.2 (8.9)3.2 (12.9)3.7 (14.7)3.1 (12.5)3.5 (13.9)3.3 (13.3)25 g
      Vitamin A (mg)98.7 (11)32.4 (3.6)85.7 (9.5)85.6 (9.5)151.9 (16.9)122.4 (13.6)122 (13.6)117.5 (13.1)102.9 (11.4)900 mg
      Thiamin (mg)0.3 (28.4)0.3 (25.7)0.3 (22.9)0.3 (25.5)0.5 (38.2)0.3 (27.3)0.3 (26.4)0.3 (27.2)0.6 (46.8)1.2 mg
      Riboflavin (mg)0.4 (34.5)0.3 (24.7)0.4 (31.8)0.3 (29)0.7 (55.5)0.5 (38.4)0.4 (34.7)0.3 (27.9)0.5 (42)1.2 mg
      Niacin (mg)3.2 (21.2)1.9 (12.8)2.7 (17.8)3 (20.1)4.3 (28.4)2.9 (19.6)3.6 (23.9)3.3 (21.9)4.8 (31.8)15 mg
      Vitamin B6 (mg)0.2 (13.3)0.1 (9.6)0.1 (8.8)0.1 (11.3)0.2 (18.3)0.2 (11.6)0.3 (20.1)0.2 (13.8)0.3 (20.3)1.3 mg
      Vitamin B12 (μg)0.5 (22.4)0.1 (6.1)0.5 (19)0.5 (21.6)1.1 (45.1)0.5 (20.1)0.9 (37.8)0.3 (13.1)0.7 (30.7)2.4 μg
      Vitamin C (mg)1.6 (1.8)0.8 (0.9)0.3 (0.3)1.5 (1.7)0.4 (0.5)3.3 (3.7)11.3 (12.6)8.4 (9.3)0.9 (1)90 mg
      Vitamin D (μg)0.6 (11.8)0.2 (4.4)0.1 (1.1)0.6 (12.4)2.2 (44.6)0.6 (11.9)1.7 (34.5)0.7 (13.3)0.6 (13)5 μg
      Calcium (mg)167.4 (12.9)84.6 (6.5)138.2 (10.6)155.1 (11.9)314.3 (24.2)89.5 (6.9)265.1 (20.4)120 (9.2)209 (16.1)1300 mg
      Iron (mg)2.4 (13.5)1.8 (10.1)1.9 (10.5)2.4 (13.4)3.1 (17.2)2.4 (13.5)2.4 (13.6)3 (16.9)3.1 (17.1)18 mg
      Potassium (mg)352.7 (7.5)209.2 (4.5)314.2 (6.7)292.2 (6.2)553.9 (11.8)366.6 (7.8)538.3 (11.5)385.5 (8.2)331.8 (7.1)4700 mg
      Magnesium (mg)44.9 (10.7)26.6 (6.3)33.2 (7.9)34.4 (8.2)66.9 (15.9)44 (10.5)56 (13.3)53.1 (12.6)64.9 (15.5)420 mg
      Zinc (mg)1.5 (14)3.6 (32.5)1 (9.1)1.3 (11.9)2 (18)1.2 (11)1.7 (15.1)1.6 (14.2)1.9 (17.1)11 mg
      Sodium (mg)409.3 (17.8)247.1 (10.7)399.4 (17.4)407.5 (17.7)427.2 (18.6)417.1 (18.1)581.1 (25.3)299.7 (13)707.4 (30.8)2300 mg
      Mean NRF9.3 score
      NRF9.3 = Nutrient-Rich Foods Index 9.3.
      627.1539.2579.5634.6729.7640.3618.5688.7613.4
      a NRF9.3 = Nutrient-Rich Foods Index 9.3.
      b ELANS = Latin American Study of Nutrition and Health.
      c Nutrient intakes and NRF9.3 score were calculated from the average of 2 nonconsecutive 24-hour dietary recalls (24HRs), for individuals who had breakfast in both 24HRs, and one 24HR, for individuals with breakfast in only one 24HR.
      d DRV = Daily Reference Value.
      e Expressed as percentage of breakfast energy.
      f TEI = total energy intake.
      Individuals in the highest NRF9.3 tertile (higher daily diet quality) had a median energy intake at breakfast of 410 kcal for adolescents (25% TEI) and 325 kcal for adults (20% TEI). The higher energy intake resulted in a higher contribution of breakfast to the intake of most nutrients in adolescents compared with adults.
      When comparing the mean NRF9.3 score among countries, Colombia had the highest score in the upper tertile, and therefore was the country with the highest breakfast quality (Tables 3 and 4). This is mainly because Colombia had the highest intakes of most nutrients to encourage (6 of 9 in the adolescents and 7 of 9 in the adults) compared with the other countries. Also, this country’s breakfast overcontributed (relative to energy) to the intake of protein and saturated fat and contributed to approximately half of the recommended daily intake of riboflavin, vitamin B12, and vitamin D. On the other hand, Argentina had the lowest upper tertile NRF9.3 score, and consequently the lowest breakfast quality among the ELANS cohort. This is probably related to the lowest intake of most nutrients to encourage (7 out of 9 in adolescents and adults) and highest proportion of added sugar in relation to the daily referencea nutrient to limiteven though this country had the lowest intake of saturated fat and sodium (the other 2 nutrients to limit) in the adult group. It is also worth noticing the very low intake of vitamin D and zinc reported in the Brazilian breakfast for both age groups.

      Food Group Intakes at Breakfast by Daily Diet Quality

      The mean intake of food groups consumed per tertile of daily diet quality and age group at breakfast are shown on Table 5 (available at www.jandonline.org). Many food groups varied across tertiles in the expected direction (ie, higher intakes of reduced-fat milk and coffee/tea with milk [for both age groups] and fruits [only for adults]) and lower intakes of non–whole grains, crackers, butter/margarine in adolescents and adults and sweet bakery products, soft drink, coffee/tea without milk, sugar/honey, meats, and white rice only in adults of tertile 3 compared with other tertiles of NRF9.3, which resulted in a distinct contribution of nutrients by these food groups (data not shown).
      Tables 6 and 7 show the frequency and mean intakes of food groups at breakfast analyzed only for the upper tertile of NRF9.3 among adolescents and adults. The 10 most frequently eaten food groups at breakfast by the upper tertile were white bread, rolls, and tortillas (60%); butter and margarine (40%); coffee and tea without milk (34% adolescents and 50% adults); whole milk (28% adolescents and 18% adults); cheese (28% adolescents and 31% adults); eggs (26%); cooked cereal and flour (20%); vegetables (21% adolescents and 18% adults); fruits (20%); and coffee and tea with milk (18% adolescents and 27% adults).
      Table 6Frequency and mean food group intake at breakfast (grams) among 378 adolescents of the upper NFR 9.3
      NRF9.3 = Nutrient-Rich Foods Index 9.3.
      tertile
      Mean food group intake and NFR9.3 tertile (for entire day) were calculated from the average of 2 nonconsecutive 24-hour dietary recalls (24HRs), for individuals who had breakfast in both 24HRs, and one 24HR, for individuals with breakfast in only one 24HR.
      who participated in the 2014-2015 ELANS
      ELANS = Latin American Study of Nutrition and Health.
      study
      Food groupELANS (n = 378)Argentina (n = 42)Brazil (n = 68)Chile (n = 37)Colombia (n = 48)Costa Rica (n = 38)Ecuador (n = 42)Peru (n = 54)Venezuela (n = 49)
      %
      Percentage represents the frequency of food group intakes at breakfast per tertile.
      mean ± SD%mean ± SD%mean ± SD%mean ± SD%mean ± SD%mean ± SD%mean ± SD%mean ± SD%mean ± SD
      Breads, rolls, tortillasnon–whole grain6170 ± 505270 ± 418176 ± 655768 ± 215877 ± 436648 ± 206073 ± 457867 ± 602085 ± 51
      Butter and/or margarine3910 ± 8149 ± 135314 ± 9497 ± 3586 ± 3298 ± 53114 ± 12138 ± 12598 ± 5
      Coffee and tea (without milk)34239 ± 16357304 ± 16422201 ± 1378201 ± 1734281 ± 7237303 ± 9340246 ± 1924346 ± 12341236 ± 247
      Milk, plain or flavored, whole28261 ± 11521207 ± 13026273 ± 14719216 ± 2365273 ± 1235282 ± 1438268 ± 3428246 ± 9616296 ± 175
      Cheese2842 ± 321070 ± 561839 ± 272429 ± 132538 ± 28842 ± 304348 ± 312628 ± 156948 ± 38
      Eggs and omelets2758 ± 37748 ± 67734 ± 381664 ± 596771 ± 342457 ± 293352 ± 272854 ± 313550 ± 42
      Cooked cereals (oatmeal and grits) and flour2144 ± 29517 ± 181277 ± 431923 ± 163334 ± 2400727 ± 10442 ± 208248 ± 25
      Vegetables, excluding potatoes2165 ± 942280 ± 04242 ± 273844 ± 142198 ± 1303449 ± 812452 ± 673343 ± 334151 ± 58
      Fruits20169 ± 1325124 ± 2818150 ± 613586 ± 6633248 ± 15111303 ± 21931217 ± 1481984 ± 568122 ± 87
      Coffee and tea (with milk)18303 ± 21717302 ± 1940267 ± 951695 ± 13510564 ± 62016440 ± 2777257 ± 34253 ± 8122334 ± 93
      Milk, plain or flavored, nonfat/low fat or reduced fat17119 ± 12912105 ± 1011260 ± 035250 ± 863875 ± 11934152 ± 1511221 ± 9002027 ± 13
      100% juice16276 ± 1262252 ± 013372 ± 1210021264 ± 7511214 ± 11031309 ± 13020290 ± 14322178 ± 94
      Cured meats/poultry1437 ± 29528 ± 111533 ± 29524 ± 131742 ± 251646 ± 46727 ± 51344 ± 432934 ± 24
      Red meat, poultry and seafood1381 ± 732351 ± 0792 ± 78860 ± 4015102 ± 6032 ± 010101 ± 562660 ± 572972 ± 68
      Rice, white12146 ± 7500347 ± 19001596 ± 3732156 ± 5712150 ± 5828197 ± 78862 ± 25
      Smoothies and grain drinks (licuado and horchata)11409 ± 2142712 ± 03916 ± 9300000031461 ± 24346331 ± 1232353 ± 0
      Fruit drinks10293 ± 22710540 ± 3356175 ± 19516213 ± 1048133 ± 11021232 ± 1725237 ± 1122126 ± 018446 ± 231
      Beans, peas, legumes882 ± 6200489 ± 11100447 ± 53996 ± 425104 ± 1071169 ± 89643 ± 28
      Sugars and honey710 ± 1153 ± 078 ± 732 ± 0620 ± 23523 ± 221212 ± 1177 ± 486 ± 3
      Sweet bakery products742 ± 221750 ± 29355 ± 331644 ± 191038 ± 23529 ± 11224 ± 000428 ± 11
      Yogurt6203 ± 7112251 ± 657197 ± 9827172 ± 552207 ± 0005272 ± 552162 ± 000
      Crackers649 ± 651768 ± 1031548 ± 5400826 ± 5530 ± 90000256 ± 0
      Ready-to-eat cereals657 ± 451034 ± 1400883 ± 103673 ± 251867 ± 471043 ± 15222 ± 0255 ± 0
      Breads, rolls, tortillaswhole grain656 ± 51228 ± 0150 ± 01168 ± 10636 ± 24832 ± 117117 ± 1331547 ± 2500
      White potatoes6110 ± 87240 ± 01100 ± 0004176 ± 157000030108 ± 884102 ± 66
      Jams, syrups, toppings632 ± 55515 ± 4427 ± 241118 ± 9823 ± 141169 ± 12900933 ± 2900
      Regular soft drinks2280 ± 642249 ± 0003260 ± 02355 ± 0002312 ± 02161 ± 04311 ± 0
      a NRF9.3 = Nutrient-Rich Foods Index 9.3.
      b Mean food group intake and NFR9.3 tertile (for entire day) were calculated from the average of 2 nonconsecutive 24-hour dietary recalls (24HRs), for individuals who had breakfast in both 24HRs, and one 24HR, for individuals with breakfast in only one 24HR.
      c ELANS = Latin American Study of Nutrition and Health.
      d Percentage represents the frequency of food group intakes at breakfast per tertile.
      Table 7Frequency and mean food group intake at breakfast (grams) among 2522 adults of the upper NFR 9.3
      NRF9.3 = Nutrient-Rich Foods Index 9.3.
      tertile
      Mean food group intake and NFR9.3 tertile (for entire day) were calculated from the average of 2 nonconsecutive 24-hour dietary recalls (24HRs), for individuals who had breakfast in both 24HRs, and one 24HR, for individuals with breakfast in only one 24HR.
      who participated in the 2014-2015 ELANS
      ELANS = Latin American Study of Nutrition and Health.
      study
      Food groupsELANS (n = 2522)Argentina (n = 335)Brazil (n = 531)Chile (n = 242)Colombia (n = 312)Costa Rica (n = 350)Ecuador (n = 219)Peru (n = 219)Venezuela (n = 314)
      %
      Percentage represents the frequency of food group intakes at breakfast per tertile.
      mean ± SD%mean ± SD%mean ± SD%mean ± SD%mean ± SD%mean ± SD%mean ± SD%mean ± SD%mean ± SD
      Breads, rolls, tortillasnon–whole grain6062 ± 344156 ± 337359 ± 257270 ± 285976 ± 516051 ± 346556 ± 337655 ± 273376 ± 36
      Butter and/or margarine4010 ± 131010 ± 65813 ± 8478 ± 5527 ± 7426 ± 53311 ± 121613 ± 50529 ± 7
      Coffee and tea (without milk)50269 ± 29975508 ± 44743162 ± 1594218 ± 15457115 ± 36470289 ± 11958224 ± 6735300 ± 8354243 ± 149
      Milk, plain or flavored, whole18238 ± 1528146 ± 13715213 ± 1638260 ± 8658266 ± 155236 ± 122226 ± 10116265 ± 16410189 ± 141
      Cheese3137 ± 25937 ± 302138 ± 292640 ± 213133 ± 212827 ± 254840 ± 242428 ± 216842 ± 26
      Eggs and omelets2657 ± 35743 ± 63853 ± 621457 ± 325768 ± 344154 ± 213340 ± 213258 ± 273053 ± 30
      Cooked cereals (oatmeal and grits) and flour2047 ± 50166 ± 311167 ± 491132 ± 473627 ± 12742 ± 23233 ± 196201 ± 1467743 ± 22
      Vegetables, excluding potatoes1862 ± 74141 ± 13448 ± 46583 ± 4822102 ± 1094738 ± 653177 ± 752656 ± 572550 ± 47
      Fruits20176 ± 1537180 ± 15523161 ± 13133156 ± 17418252 ± 20520142 ± 12534228 ± 14721124 ± 868161 ± 135
      Coffee and tea (with milk)27252 ± 13724310 ± 11751227 ± 982457 ± 9822241 ± 14426352 ± 13616257 ± 417324 ± 14926344 ± 135
      Milk, plain or flavored, nonfat/low fat or reduced fat16111 ± 13812146 ± 1124204 ± 23228234 ± 1423445 ± 742590 ± 11814119 ± 1182368 ± 1401837 ± 76
      100% juice11282 ± 1904204 ± 1458336 ± 2342148 ± 13410251 ± 1105290 ± 17827288 ± 17125329 ± 22012190 ± 119
      Cured meats/poultry1328 ± 19223 ± 10925 ± 171728 ± 141234 ± 311822 ± 16933 ± 181131 ± 192829 ± 18
      Red meat, poultry, and seafood1066 ± 50149 ± 41442 ± 31240 ± 17970 ± 501139 ± 302284 ± 542570 ± 521667 ± 54
      Rice, white9121 ± 8100160 ± 170012101 ± 454096 ± 5916124 ± 6714197 ± 106275 ± 80
      Smoothies and grain drinks (licuado and horchata)9357 ± 1671641 ± 4592291 ± 126003278 ± 1742347 ± 20822377 ± 16244354 ± 1473326 ± 193
      Fruit drinks5244 ± 1764245 ± 1535206 ± 2345255 ± 2903172 ± 11710221 ± 1421238 ± 12262 ± 829324 ± 98
      Beans, peas, legumes670 ± 7218 ± 11125 ± 2100369 ± 604276 ± 70890 ± 121626 ± 27589 ± 47
      Sugars and honey810 ± 1087 ± 6615 ± 14617 ± 15137 ± 4610 ± 1095 ± 5811 ± 10613 ± 14
      Sweet bakery products449 ± 381253 ± 42455 ± 39337 ± 39329 ± 19941 ± 30140 ± 36277 ± 140140 ± 0
      Yogurt3191 ± 861182 ± 442227 ± 11411154 ± 572246 ± 133004241 ± 803176 ± 820249 ± 0
      Crackers1129 ± 183528 ± 141229 ± 25621 ± 8833 ± 181230 ± 11539 ± 19531 ± 22326 ± 2
      Ready-to-eat cereals351 ± 47434 ± 20232 ± 30638 ± 24587 ± 72540 ± 291123 ± 25215 ± 11362 ± 44
      Breads, rolls, tortillaswhole grain1064 ± 59787 ± 50746 ± 261070 ± 321191 ± 1152259 ± 421462 ± 611452 ± 24248 ± 6
      White potatoes5130 ± 1221112 ± 1632198 ± 2220011135 ± 104113 ± 13785 ± 6917113 ± 973251 ± 168
      Jams, syrups, toppings719 ± 132118 ± 10128 ± 181920 ± 11719 ± 13510 ± 1218 ± 4233 ± 26119 ± 15
      Soft drinks1306 ± 1221330 ± 1621260 ± 60000332 ± 00250 ± 02213 ± 654331 ± 1312338 ± 132
      a NRF9.3 = Nutrient-Rich Foods Index 9.3.
      b Mean food group intake and NFR9.3 tertile (for entire day) were calculated from the average of 2 nonconsecutive 24-hour dietary recalls (24HRs), for individuals who had breakfast in both 24HRs, and one 24HR, for individuals with breakfast in only one 24HR.
      c ELANS = Latin American Study of Nutrition and Health.
      d Percentage represents the frequency of food group intakes at breakfast per tertile.
      Tables 6 and 7 also demonstrate the variety of foods consumed at breakfast between countries. Among adolescents, the upper tertile breakfast eaters in Venezuela distinguish themselves from other countries by the high frequency of consumption of butter/margarine, cheese, cooked cereals/flour (for both age groups), and vegetables, and all types of meat (for adolescents). In Colombia, breakfast is distinguished by the higher frequency of intake of all types of milk and eggs. In Costa Rica, there is a higher frequency of intake of white rice, beans/peas/legumes, and vegetables (for both age groups). Other distinguishing food groups included the higher frequency of intake of 100% juice (for both age groups), sugar/honey (for adolescents), and fruits (for adults) in Ecuador; the higher frequency of intake of smoothies/grain drinks (for both age groups), white bread/rolls/tortillas, and red meats/poultry/seafood (for adults) in Peru; the higher frequency of intake of coffee/tea with milk (for both age groups), white bread/rolls/tortillas (for adolescents), and butter/margarine (for adults) in Brazil; the higher frequency of intake of coffee/tea without milk (for both age groups) in Argentina; the higher frequency of intake of yogurt (for both age groups) and fruits (for adolescents) in Chile.

      Nutrient Recommendation for Breakfast

      Based on the analyses of NRF9.3 tertile 3 and the identification of food choices and nutrient intakes that were associated with highest quality diets, a proposed nutrient recommendation for a balanced breakfast in LA based on 5 guiding principles separated for adolescents and adults was summarized in Table 8.
      Table 8Proposed nutrient recommendations for breakfast based on the average nutrient intake of adolescents and adults of the upper NFR9.3
      NRF9.3 = Nutrient-Rich Foods Index 9.3.
      tertile who participated in the 2014-2015 ELANS
      ELANS = Latin American Study of Nutrition and Health.
      study
      NutrientAdolescents (1-19 y)Adults (20-65 y)DRV
      RecommendedELANS
      ELANS sample size was composed of 378 adolescents and 2522 adults of the upper NFR9.3 tertile.
      RecommendedELANS
      ELANS sample size was composed of 378 adolescents and 2522 adults of the upper NFR9.3 tertile.
      %kcal or DRVRange%kcal or DRVRange
      Principle 1 (value closer to the midpoint of the range)
      Energy (kcal)
      Based on a 2000 kcal diet
      400-600300-600
      Energy (% TEI)
      TEI = total energy intake
      2518-282014-28
      Principle 2 (lower range of the median intake of T3)
      Protein (% DRV)
      DRV = Daily Reference Values.
      >202718-31>152314-3350 g
      Niacin (% DRV)>202419-34>152113-3215 mg
      Vitamin B6 (% DRV)>10179-26>10139-201.3 mg
      Vitamin B12 (% DRV)>103212-51>5226-452.4 μg
      Principle 3 (average intake range of T3)
      Thiamin (% DRV)>353327-52>302823-471.2 mg
      Riboflavin (% DRV)>404242>353525-421.2 mg
      Total carbohydrates (% kcal breakfast)
      % kcal breakfast = percentage of breakfast calories.
      45-655552-6645-655551-6545%-65% TEI
      Principle 4 (value of the country with the higher percentage of contribution)
      Fiber (% DRV)>14127-14>15115-1525 g
      Vitamin A (% DRV)>20147-20>17114-17900 mg
      Vitamin C (% DRV)>1251-12>1320-1390 mg
      Vitamin D (% DRV)>25202-54>20121-455 μg
      Calcium (% DRV)>25179-26>20137-201300 mg
      Iron (% DRV)>201613-20>171310-1718 mg
      Potassium (% DRV)>1595-15>1284-124700 mg
      Magnesium (% DRV)>17127-17>16116-16420 mg
      Zinc (% DRV)>221613-22>18149-1811 mg
      Sodium (% DRV)<252013-35<201811-312300 mg
      Principle 5 (WHO
      WHO = World Health Organization.
      guideline values expressed as percentage of breakfast energy intake)
      Added sugar (% kcal breakfast)<10105-21<10105-11<10% TEI
      Total fat (% kcal breakfast)20-30282-3620-302819-33<30% TEI
      Saturated fat (% kcal breakfast)<10116-14<10107-12<10% TEI
      a NRF9.3 = Nutrient-Rich Foods Index 9.3.
      b ELANS = Latin American Study of Nutrition and Health.
      c ELANS sample size was composed of 378 adolescents and 2522 adults of the upper NFR9.3 tertile.
      d Based on a 2000 kcal diet
      e TEI = total energy intake
      f DRV = Daily Reference Values.
      g % kcal breakfast = percentage of breakfast calories.
      h WHO = World Health Organization.
      Principle 1 was based on the contribution of breakfast to daily energy intake. Among adolescents, the contribution ranged from 18% to 28% and among adults it ranged from 14% to 28%, depending on the country. As a result, a value closer to the midpoint of the range was proposed as a benchmark for setting a percentage of energy (%) and nutrient recommendations: for adolescents 25% and for adults 20% of daily energy. Based on a 2000 kcal diet, the recommend range of energy intake (kcal) at breakfast for the adolescents ranged from 400 to 600 kcal (18%-28% of 2000 kcal) and for the adults from 300 to 600 kcal (14%-28% of 2000 kcal).
      Principle 2 was applied to protein, niacin, and vitamins B6 and B12, in which the median daily intake was higher than DRV. For adolescents, the target of protein and niacin was >20% and for vitamins B6 and B12 was >10%. For adults, the target was >15% of protein, >15% of niacin, >10% of vitamin B6, and >5% of vitamin B12.
      Principle 3 was applied to carbohydrates, thiamin, and riboflavin, in which the median population intakes were close to the reference values (DRV and Acceptable Macronutrient Distribution Range),
      Institute of Medicine
      Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids.
      and breakfast contributed significantly to daily intakes of these nutrients (>25% for adolescents and >20% for adults). The target was then set to the average intakes range from individuals in the upper NRF9.3 tertile; therefore, >35% for thiamin and >40% for riboflavin among adolescents and >30% and 35% for adults. As for carbohydrates, the Acceptable Macronutrient Distribution Range recommendation of 45% to 65% of TEI was used.
      Principle 4 was applied to calcium; fiber; vitamins A, C, and D; iron; potassium; magnesium; and zinc, since the ELANS population median intake was below the DRV and there was wide variation in breakfast contribution across countries in both age groups. The proposed target for each of these nutrients was determined by taking the highest percentage of intake observed in a LA country. In the case of vitamin D, calcium, and sodium, as higher percentage of intake in the range exceeded the mean energy contribution of breakfast (for example, vitamin D in adolescents ranged from 2% to 54% and mean energy intake was 25%), the mean energy contribution was used as target instead of the higher intake in the range. As sodium consumption should not be encouraged, the same principle was applied as a maximum threshold rather than the minimum requirement (<25% for adolescents and < 20% to adults).
      Principle 5 was applied to added sugar, total fat, and saturated fat, in which the consumption should be limited. As a result, the proposal was to limit to 10% breakfast energy for sugars and saturated fat, and up to 30% for total fats.
      FAO
      Fats and Fatty Acids in Human Nutrition. Report of an Expert Consultation.
      ,
      WHO
      Guideline: Sugars Intake for Adults and Children.

      Discussion

      This study confirms the importance of breakfast on overall diet quality in both adolescents and adults. Among those with higher daily diet quality, breakfast was consistently shown to be a nutrient-rich eating occasion relative to its contribution to daily energy and a positive contributor of B vitamins, protein, and carbohydrates intakes, although it was a negative contributor of added sugar and total and saturated fat intakes for all countries. By observing the nutritional profile of the individuals with the best daily diet quality, along with the current international dietary guidelines, nutrient-based recommendations for a balanced breakfast were developed for the first time in LA. Also, by exploring the food groups most commonly consumed in the region and specifically for each country, inferences could be made about the food groups that should be encouraged or reduced by this population, respecting their cultural habits.
      Diets that scored in the upper NRF9.3 tertile were associated with a better level of intake at breakfast of some key micronutrients such as vitamins A and D and calcium, although some variability was observed among age groups and countries. Previous studies have also shown higher micronutrient intakes and improved overall dietary adequacy in breakfast consumers.
      • Barr S.I.
      • DiFrancesco L.
      • Fulgoni 3rd, V.L.
      Consumption of breakfast and the type of breakfast consumed are positively associated with nutrient intakes and adequacy of Canadian adults.
      • Barr S.I.
      • DiFrancesco L.
      • Fulgoni 3rd, V.L.
      Breakfast consumption is positively associated with nutrient adequacy in Canadian children and adolescents.
      • Pereira J.L.
      • Castro M.A.
      • Hopkins S.
      • Gugger C.
      • Fisberg R.M.
      • Fisberg M.
      Prevalence of consumption and nutritional content of breakfast meal among adolescents from the Brazilian National Dietary Survey.
      Interestingly, energy content of breakfast was significantly higher in the bottom NRF9.3 tertile for both age groups, which could be explained by the higher intake of carbohydrate, protein (only in adults), and total and saturated fat of the individuals in this tertile. The differences observed in nutrient intakes are likely explained by the differences in food choice across the tertiles. In the bottom NRF9.3 tertile, for example, there was a higher amount and frequency of consumption of foods such as refined bread and butter/margarine for both age groups and all types of meat, rice, sweet bakery products, soft drinks, and sugar/honey in adults. On the other hand, the highest NRF9.3 tertile had a higher overall amount and frequency of consumption of healthy food groups such as low-fat milk (for both age groups) and fruits (only in adults). These findings are in line with the findings from IBRI participating countries
      • Barr S.I.
      • Vatanparast H.
      • Smith J.
      Breakfast in Canada: Prevalence of consumption, contribution to nutrient and food group intakes, and variability across tertiles of daily diet quality. A study from the International Breakfast Research Initiative.
      • Bellisle F.
      • Hebel P.
      • Salmon-Legagneur A.
      • Vieux F.
      Breakfast consumption in French children, adolescents, and adults: A nationally representative cross-sectional survey examined in the context of the International Breakfast Research Initiative.
      • Drewnowski A.
      • Rehm C.D.
      • Vieux F.
      Breakfast in the United States: Food and nutrient intakes in relation to diet quality in National Health and Examination Survey 2011-2014. A study from the International Breakfast Research Initiative.
      • Fagt S.
      • Matthiessen J.
      • Thyregod C.
      • Korup K.
      • Biltoft-Jensen A.
      Breakfast in Denmark. Prevalence of consumption, intake of foods, nutrients and dietary quality. A study from the International Breakfast Research Initiative.
      • Gaal S.
      • Kerr M.A.
      • Ward M.
      • McNulty H.
      • Livingstone M.B.E.
      Breakfast consumption in the UK: Patterns, nutrient intake and diet quality. A study from the International Breakfast Research Initiative Group.
      • Ruiz E.
      • Avila J.M.
      • Valero T.
      • Rodriguez P.
      • Varela-Moreiras G.
      Breakfast consumption in Spain: Patterns, nutrient intake and quality. Findings from the ANIBES Study, a study from the International Breakfast Research Initiative.
      except for dairy groups (eg, yogurt, cheese), juices, and eggs, which did not differ across NRF9.3 tertiles in the present study.
      It is noteworthy that the most frequently consumed foods at breakfast are not completely in agreement with the recommended breakfast composition outlined in the national guidelines available in LA.
      Brasil, Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica
      ,
      • Ministerio de Salud de la Nacion.
      White bread/rolls/tortillas was the most consumed food group by approximately 60% of all consumers of both age groups. On the other hand, the absolute level of intake of whole-grain products was low (<10% of consumers of both age groups). These observations might explain the low fiber intake and suggest that an increase in fiber content could be recommended to this population, including for those individuals with a better diet quality. Notably, fresh fruits were consumed at breakfast by only 15% of consumers of both age groups. Besides the low fiber consumption, these findings might also explain the low vitamin C intake, which clearly represents an opportunity for needed improvement. Considered together, the poor food choices at breakfast are likely contributing to the suboptimal intake of some nutrients at this meal (eg, high contribution of added sugar and saturated fat, and low contribution to vitamin C and fiber intakes), which could be improved by the higher consumption of fruits, vegetables, whole grains, and low-fat dairy and lower consumption of non–whole grains and animal and sugary products.
      Age differences in breakfast micronutrient intakes were observed between adolescents and adults of the highest NRF9.3 tertile. Adolescents within the highest tertile had significantly higher intakes of vitamins A, B12, D and calcium and potassium compared with the lowest tertile, whereas adults within the highest tertile had significantly higher intakes of calcium and potassium compared with the lowest tertile. Both age groups had lower intake of sodium in the highest tertile compared with the lowest tertile. Probably due to the high intake of carbohydrates and proteins, adults of the lowest tertile had higher intakes of niacin, iron, and sodium compared with the highest tertile. These findings underline the importance of breakfast as a micronutrient-rich meal, especially in adolescents, and reinforce the importance of maintaining healthful eating habits that continue when entering adulthood.
      • Movassagh E.Z.
      • Baxter-Jones A.D.G.
      • Kontulainen S.
      • Whiting S.J.
      • Vatanparast H.
      Tracking dietary patterns over 20 years from childhood through adolescence into young adulthood: The Saskatchewan Pediatric Bone Mineral Accrual Study.
      Differences in breakfast nutritional quality and food composition were observed among participating countries. The highest score in the upper tertile reported in Colombia is likely to be driven by the best combination of nutrients to encourage and nutrients to limit (especially added sugar). This higher nutrient density could be explained by the large variety of food groups consumed in the Colombian breakfast (eg, refined bread, cereal, and flour; butter and/or margarine; coffee/tea; milk; cheese; egg; vegetables). Argentina, on the other hand, had the lowest upper tertile score, with breakfast typically low in micronutrients and rich in added sugar, which could be explained by a low diversity of food groups typically eaten in breakfast (eg, refined bread and grains and coffee/tea without milk). These findings are potentially influenced by the different average energy intake between countries (notably Argentina), but once more underline that the cultural diversity might have contributed to different breakfast composition and diet quality among LA countries. Furthermore, the wide range of intake observed for nutrients at breakfast, such as vitamin D, could be related not only to cultural habits, but also to differences in food fortification policies among the 8 countries.
      The nutrient recommendations for breakfast were based on the existing LA breakfast intakes, considering the nutritional profiles of ELANS tertile 3 and conforming with the current DRVs. Therefore, they are realistic and feasible, aiming to maintain nutrient density while improving intakes for nutrients of public health concern (eg, added sugars, saturated fats, fiber, and vitamin D). This information could be applied in each country to support food choice recommendations based in quantitative data. For example, in Brazil, encouraging fruit intake at breakfast (which is a culturally acceptable intervention) could improve the fiber and vitamin C content of this meal; likewise, introducing a serving of protein and reducing the sugar intake in Argentina’s breakfast would improve the quality of this meal. Despite considering the intake of each country as a unit, the proposed recommendations are close to the mean intake observed in the overall ELANS sample. In addition, the recommendations were divided by age group and expressed in percentage so it could be tailored to DRVs.
      The main strengths of the present study include the use of a large multicenter representative sample of 8 LA countries, with simultaneous application of dietary recall over 2 individual nonconsecutive days across countries following a standardized methodology. This feature of the ELANS study enables the development of nutrient recommendations adapted to the current patterns of breakfast in the evaluated countries. The approach proposed by the IBRI project, based on optimal nutrients intake rather than food groups, was appropriate for the LA region, considering that breakfast possess distinct dietary patterns among LA countries, besides being different from European and North American countries studied in this project. Indeed, compared with IBRI recommendations, lower recommended values were observed in the current study specially for the nutrients of principles 2 and 4 and in the adults group. Finally, it should be noted that the present protocol based on highest daily diet quality could be used in future quantitative assessments of changes of dietary habits or to evaluate and follow up on nutritional interventions, which could be used for between- or within-countries comparisons.
      The ELANS study group is aware that with the cross-sectional design of the project, causal and temporal inference is not possible. Also, as ELANS data represented the dietary intake of the urban population of 8 countries of LA, caution should be used to extrapolate these findings to rural population or other countries of the region. Although dietary data from the rural population was absent, it should be highlighted that the majority of the LA population lives in the urban setting (64%-92% of the population).
      World Bank
      Urban population (% of total population).
      Although the recommendations for a balanced breakfast were based on the midpoint of the range of intake of the highest NRF9.3 tertile, the average energy contribution of breakfast is used as reference to set guidelines for other nutrients (eg, principles 1 and 5). Therefore, countries where daily nutrient intakes are lower than the reference of the current study should approach the recommendations cautiously. It is important to note that data analyses were based on the two 24HR, which may be susceptible to some limitations, such as memory-related errors, underreporting of energy intake, and examiner effects.
      • Gibson R.S.
      • Charrondiere U.R.
      • Bell W.
      Measurement errors in dietary assessment using self-reported 24-hour recalls in low-income countries and strategies for their prevention.
      Although it is a reliable instrument to assess nutrient intakes of populations,
      • Gibson R.S.
      Principles of Nutritional Assessment.
      it is possible that some subjects could have been incorrectly identified as “breakfast skippers” and therefore excluded from the final sample.
      The results of the present study pave the way for future research of each LA country involved in the ELANS to explore food habits at breakfast and consequently tailor the nutritional recommendations for a balanced breakfast at a country level, investigating their specific strengths and windows of opportunity and allowing the adaptation for tangible targets according to local and feasible habits. These nutrient recommendations for balanced breakfast will be of value for health professionals, policy makers, educators, food manufacturers, food retailers, and researchers to assist consumers to optimize food choices at breakfast.

      Conclusion

      The current study showed that NRF9.3 provided a harmonized approach to identify high-quality breakfasts within each country. Individuals with higher daily diet quality (upper NRF9.3 tertile) had a higher intake at breakfast of nutrients to encourage (vitamins A and D, calcium, and potassium for adolescents and fiber, calcium, and potassium for adults) and lower intake of nutrients to limit (added sugar, saturated fat, and sodium for both age groups) compared with those with lower diet quality. These findings allowed the development of nutrient-based recommendations for a balanced breakfast for the first time in LA, which may contribute to a better nutrient intake and help LA breakfast consumers make healthier choices at this meal.

      Acknowledgements

      We thank the staff and participants from each of the participating sites who made substantial contributions to the ELANS. The following are members of ELANS Study Group: chairs: Mauro Fisberg and Irina Kovalskys; cochair: Georgina Gómez Salas; Core Group members: Attilio Rigotti, Lilia Yadira Cortés Sanabria, Martha Cecilia Yépez García, Rossina Gabriella Pareja Torres, and Marianella Herrera-Cuenca; External Advisory Board: Berthold Koletzko, Luis A. Moreno, Regina Mara Fisberg, and Michael Pratt; project managers: Viviana Guajardo and Ioná Zalcman Zimberg.

      Author Contributions

      All authors were involved in the conception and design of the overall research plan. M. Fisberg, I. Kovalskys, G. Gómez, A. Rigotti, L. Y. Cortés Sanabria, M. Herrera-Cuenca, M. C. Yépez García, and M. R. Liria Domínguez designed and conducted the study and collected the data; M. Fisberg and I. Kovalskys had primary responsibility for the final content of the manuscript; I. Z. Zimberg and J. L. Pereira wrote the paper; A. N. Previdelli and J. L. Pereira analyzed data; V. Guajardo and G. Ferrari assisted with the interpretation of results and provided critical review of the manuscript. All authors read and approved the final manuscript.

      Supplementary Materials

      Table 2Mean energy and nutrient intake at breakfast of the 8714 breakfast consumers (1140 adolescents and 7574 adults) by NFR 9.3
      NRF9.3 = Nutrient-Rich Foods Index 9.3.
      tertile
      Mean energy and nutrient intakes at breakfast and the NFR9.3 tertile (for entire day) were calculated from the average of 2 nonconsecutive 24-hour dietary recalls (24HRs), for individuals who had breakfast in both 24HRs, and one 24HR, for individuals with breakfast in only one 24HR.
      , from the 2014-2015 ELANS
      ELANS = Latin American Study of Nutrition and Health.
      study
      Adolescents (15-19 y; n = 1140)Adults (20-65 y; n = 7574)
      OverallT1T2T3P value
      Kruskal Wallis test; statistically significant difference indicated by P < .05.
      OverallT1T2T3P value
      Kruskal Wallis test; statistically significant difference indicated by P < .05.
      mean ± (SD)mean ± SD
      NRF9.3 score518.5 ± 95454.3 ± 84.6518.2 ± 74.9583.7 ± 77.1<.001
      T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      558.2 ± 98.4481.7 ± 86.1557.5 ± 71635.6 ± 68.9<.001
      T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      Energy (kcal)498 ± 286545 ± 297497 ± 305452 ± 246<.001
      T1 ≠ T2 and T1 ≠ T3.
      436 ± 252506 ± 294436 ± 230366 ± 205<.001
      T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      Protein (g)16 ± 10.816 ± 10.616.4 ± 11.515.7 ± 10.3.67914.6 ± 10.616 ± 12.414.6 ± 9.913.2 ± 8.9<.001
      T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      Carbohydrate (g)71.8 ± 40.678.5 ± 40.970.4 ± 41.566.4 ± 38.4<.001
      T1 ≠ T2 and T1 ≠ T3.
      63.7 ± 35.473.8 ± 41.263 ± 31.654.2 ± 29.6<.001
      T1 ≠ T3 and T2 ≠ T3.
      Added sugar (g)18.6 ± 16.525 ± 20.817.1 ± 12.413.5 ± 12.5<.001
      T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      15.8 ± 15.222.4 ± 19.214.9 ± 12.49.9 ± 9.6<.001
      T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      Total fat (g)17.4 ± 14.819.6 ± 16.617.7 ± 15.615 ± 11.2<.001
      T1 ≠ T3 and T2 ≠ T3.
      15 ± 12.617.7 ± 15.115.1 ± 11.812.2 ± 9.7<.001
      T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      Saturated fat (g)6.5 ± 67.1 ± 7.16.6 ± 6.25.7 ± 4.4.015
      T1 ≠ T3.
      5.4 ± 56.2 ± 5.95.5 ± 4.84.5 ± 3.9<.001
      T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      Fiber (g)3.5 ± 2.83.3 ± 2.53.6 ± 33.7 ± 2.9.2843.4 ± 2.93.4 ± 2.83.4 ± 2.93.5 ± 3<.001
      T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      Vitamin A (mg)163 ± 344.7134.8 ± 139.7171.9 ± 354.7182.7 ± 460.3.021
      T1 ≠ T3.
      142 ± 269.5130 ± 155.5139.2 ± 195.5156.9 ± 394.2.668
      Thiamin (mg)0.5 ± 0.40.5 ± 0.30.5 ± 0.40.5 ± 0.3.1960.5 ± 0.30.5 ± 0.30.5 ± 0.30.4 ± 0.3.025
      T1 ≠ T3 and T2 ≠ T3.
      Riboflavin (mg)0.6 ± 0.40.5 ± 0.30.5 ± 0.40.6 ± 0.4.3330.5 ± 0.30.5 ± 0.30.5 ± 0.30.5 ± 0.3<.001
      T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      Niacin (mg)4.8 ± 3.75 ± 3.74.9 ± 3.94.6 ± 3.6.0854.4 ± 3.24.9 ± 3.64.4 ± 33.9 ± 3.005
      T1 ≠ T3 and T2 ≠ T3.
      Vitamin B6 (mg)0.3 ± 0.30.3 ± 0.30.3 ± 0.30.3 ± 0.3.1660.3 ± 0.30.3 ± 0.30.3 ± 0.30.3 ± 0.3<.001
      T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      Vitamin B12 (μg)1 ± 2.50.8 ± 11 ± 2.61.2 ± 3.4.008
      T1 ≠ T3.
      0.8 ± 1.90.8 ± 1.20.8 ± 1.40.9 ± 2.7.053
      Vitamin C (mg)19.3 ± 50.819.2 ± 62.716.3 ± 38.722.4 ± 48.026
      T2 ≠ T3.
      17.8 ± 61.517.7 ± 67.917.8 ± 67.718 ± 46.3.361
      Vitamin D (μg)1.3 ± 1.61.1 ± 1.41.2 ± 1.51.5 ± 1.8.011
      T1 ≠ T3.
      1.1 ± 1.71 ± 1.71.2 ± 1.91.2 ± 1.7.800
      Calcium (mg)231.2 ± 202.7204.7 ± 180.8233 ± 220.5256.3 ± 202.3.001
      T1 ≠ T3.
      197.4 ± 187.5184.2 ± 186.7196.7 ± 180.8211.1 ± 194<.001
      T1 ≠ T2 and T1 ≠ T3.
      Iron (mg)3.7 ± 2.93.8 ± 33.6 ± 2.73.5 ± 2.8.1473.2 ± 2.43.5 ± 2.33.2 ± 2.32.9 ± 2.6<.001
      T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      Potassium (mg)471.8 ± 362.1430.3 ± 311.5467.3 ± 380.2518.3 ± 386.002
      T1 ≠ T3 and T2 ≠ T3.
      436.9 ± 355.7437.4 ± 367.4424.6 ± 329.8448.5 ± 368.3<.001
      T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      Magnesium (mg)55.9 ± 37.152.7 ± 32.855.2 ± 38.459.9 ± 39.6.05153.1 ± 37.952.7 ± 37.552.3 ± 36.854.3 ± 39.4.087
      Zinc (mg)2.2 ± 1.82.2 ± 1.82.2 ± 22.2 ± 1.7.7322.4 ± 3.72.6 ± 2.82.3 ± 2.32.3 ± 5.2.217
      Sodium (mg)656.1 ± 1005.6750.9 ± 1611.5641.3 ± 479.8574.8 ± 421.1.016
      T1 ≠ T3.
      578.7 ± 584.7658 ± 607.3580.9 ± 429.9496.8 ± 677.9<.001
      T1 ≠ T3 and T2 ≠ T3.
      a NRF9.3 = Nutrient-Rich Foods Index 9.3.
      b Mean energy and nutrient intakes at breakfast and the NFR9.3 tertile (for entire day) were calculated from the average of 2 nonconsecutive 24-hour dietary recalls (24HRs), for individuals who had breakfast in both 24HRs, and one 24HR, for individuals with breakfast in only one 24HR.
      c ELANS = Latin American Study of Nutrition and Health.
      d Kruskal Wallis test; statistically significant difference indicated by P < .05.
      e T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      f T1 ≠ T2 and T1 ≠ T3.
      g T1 ≠ T3 and T2 ≠ T3.
      h T1 ≠ T3.
      i T2 ≠ T3.
      Table 5Frequency and mean food group intake at breakfast (grams) of the 8714 breakfast consumers (1140 adolescents and 7574 adults) by NFR 9.3
      NRF9.3 = Nutrient-Rich Foods Index 9.3.
      tertile
      Mean food group intake and NFR9.3 tertile (for entire day) were calculated from the average of 2 nonconsecutive 24-hour dietary recalls (24HRs), for individuals who had breakfast in both 24HRs, and one 24HR, for individuals with breakfast in only one 24HR.
      , from the 2014-2015 ELANS
      ELANS = Latin American Study of Nutrition and Health.
      study
      Adolescents 15-19 y (n = 1140)Adults 20-65 y (n = 7574)
      TotalT1T2T3P value
      Kruskal Wallis test; statistically significant difference indicated by P < .05.
      TotalT1T2T3P value
      Kruskal Wallis test; statistically significant difference indicated by P < .05.
      mean (%)mean (%)
      Milk, plain or flavored, whole252.87 (23.2)254.7 (19.3)240.9 (22.2)261.1 (28.0).57228.05 (16.7)212.3 (14.0)229.9 (17.9)238.4 (18.2).09
      Cheese43.82 (30.8)43.9 (29.3)44.9 (35.1)42.4 (28.0).7839.09 (29.6)41.4 (27.6)39 (30.8)37.1 (30.5).3
      Yogurt215.72 (4.7)231.1 (3.9)220.8 (3.7)203.1 (6.4).94200.05 (2.8)209.5 (2.7)199.5 (3.1)191.2 (2.6).85
      Red meat, poultry, and Seafood70.19 (15.6)63.6 (18.8)69.5 (15.0)80.7 (13.0).4372.39 (14.8)76.5 (19.0)71.6 (15.0)66.0 (10.4).02
      T1 ≠ T3.
      Eggs and omelets55.01 (27.5)52.6 (28.5)54.5 (27.2)58.1 (26.7).5857.39 (28.0)58.0 (28.9)57.1 (29.3)57.1 (25.9).84
      Cured meats/poultry39.50 (18.8)40.4 (22.2)40.4 (20.3)36.6 (13.8).3536.81 (16.7)42.6 (19.9)36.4 (17.6)28.3 (12.6)<.001
      T1 ≠ T3 and T2 ≠ T3.
      Beans, peas, legumes77.82 (6.4)69.0 (5.0)79.0 (6.1)82.4 (8.2).8671.90 (6.6)71.1 (6.9)74.9 (6.3)69.9 (6.5).72
      Breads, rolls, tortillas—non–whole grain73.68 (62.5)75.6 (61.6)74.9 (65.7)70.3 (60.3).04
      T1 ≠ T3.
      70.14 (62.3)78.1 (61.8)70.3 (64.8)61.8 (60.2)<.001
      T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      Ready-to-eat cereals55.96 (4.2)66.6 (2.6)46.8 (4.0)57.3 (6.1).3550.00 (2.4)50.8 (1.4)48.5 (2.4)50.7 (3.2).93
      Cooked cereals (oatmeal and grits) and flour49.30 (17.9)52.9 (17.0)52.1 (16.1)44.1 (20.6).1146.94 (18.2)46.2 (17.1)47.6 (17.7)47 (19.7).021
      T2 ≠ T3.
      Crackers48.89 (7.0)59.5 (8.1)35.7 (6.6)49 (6.4).005
      T1 ≠ T2 and T1 ≠ T3.
      35.10 (9.8)41.7 (8.9)35.9 (9.3)29.2 (11.2)<.001
      T1 ≠ T2 and T1 ≠ T3.
      Sweet bakery products69.65 (7.6)89.1 (9.9)67.7 (6.3)42.0 (6.6).0861.39 (5.7)68.3 (7.4)61.4 (5.3)49.3 (4.2).001
      T1 ≠ T3.
      Fruits155.57 (15.3)131.5 (10.7)155.7 (15.6)168.8 (19.6).32156.11 (15.4)132.7 (12.0)148.5 (14.6)176.2 (19.7)<.001
      T1 ≠ T3 and T2 ≠ T3.
      Vegetables, excluding potatoes62.44 (20.1)65.6 (19.3)57.0 (20.3)64.8 (20.6).6261.55 (20.4)65.7 (22.6)56.6 (20.9)62.1 (17.6).16
      White potatoes119.35 (4.4)157.3 (2.9)106.9 (4.5)110.0 (5.8).97125.49 (5.3)140.4 (5.6)105 (5.1)129.6 (5.1).2
      100% juice265.27 (15.8)259.1 (18.3)261.7 (13.5)275.6 (15.6).52266.81 (13.6)253.9 (16.0)269.2 (13.5)282.3 (11.2).52
      Regular soft drinks350.68 (6.8)381.2 (13.1)299.1 (5.3)280.0 (1.9).15371.84 (4.5)403.5 (9.0)308.3 (3.0)305.8 (1.4)<.001
      T1 ≠ T2 and T1 ≠ T3.
      Coffee and tea (without milk)247.17 (36.5)258.5 (38.4)242.4 (37.7)239.4 (33.3).3284.50 (50.2)307.3 (50.2)276.7 (50.8)269.4 (49.6)<.001
      T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      Butter and/or margarine12.47 (43.1)14.0 (47.8)13.4 (42.2)9.5 (39.2).002
      T1 ≠ T3.
      11.91 (45.0)14.0 (47.5)11.5 (47.1)9.8 (40.3)<.001
      T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      Sugars and honey13.35 (10.0)14.5 (13.6)14.0 (9.5)10.2 (6.9).214.36 (9.2)18.6 (10.9)12.8 (9.0)10.2 (7.7)<.001
      T1 ≠ T2 and T1 ≠ T3.
      Milk, plain or flavored, nonfat/low fat or reduced fat95.54 (14.5)58.8 (13.3)102.6 (12.9)119.0 (17.2).01
      T1 ≠ T3.
      76.40 (13.7)46.4 (12.0)62.8 (13.5)111.1 (15.7)<.001
      T1 ≠ T3 and T2 ≠ T3.
      Rice, white171.94 (11.0)203.4 (10.7)168.3 (10.3)146.4 (11.9).32155.11 (10.3)186.1 (12.0)147.3 (10.2)120.9 (8.6)<.001
      T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      Breads, rolls, tortillaswhole grain52.15 (3.1)32.3 (0.8)49.7 (2.4)55.7 (6.1).3868.68 (5.8)78.2 (2.3)73.1 (5.0)64.3 (10.0).1
      Fruit drinks262.65 (10.3)253.6 (10.7)241.8 (10.0)293.2 (10.1).48261.06 (6.4)270.6 (7.8)261.4 (6.8)244.2 (4.6).44
      Coffee and tea (with milk)240.87 (18.6)211 (17.8)213.2 (20.3)302.9 (17.7).01
      T1 ≠ T3 and T2 ≠ T3.
      230.51 (25.5)208.7 (22.9)227.1 (26.6)252.4 (27.0)<.001
      T1 ≠ T3 and T2 ≠ T3.
      Jams, syrups, toppings33.32 (6.5)43.6 (7.6)21.2 (6.1)32.5 (5.8).3125.47 (6.6)29.4 (6.2)27.9 (6.9)19.2 (6.6).05
      Smoothies and grain drinks (licuado and horchata)384.92 (9.0)374.6 (7.3)363.6 (8.7)408.6 (11.1).81361.51 (7.5)370.3 (6.3)359.6 (7.3)356.8 (8.8).6
      a NRF9.3 = Nutrient-Rich Foods Index 9.3.
      b Mean food group intake and NFR9.3 tertile (for entire day) were calculated from the average of 2 nonconsecutive 24-hour dietary recalls (24HRs), for individuals who had breakfast in both 24HRs, and one 24HR, for individuals with breakfast in only one 24HR.
      c ELANS = Latin American Study of Nutrition and Health.
      d Kruskal Wallis test; statistically significant difference indicated by P < .05.
      e T1 ≠ T3.
      f T1 ≠ T3 and T2 ≠ T3.
      g T1 ≠ T2, T1 ≠ T3, and T2 ≠ T3.
      h T2 ≠ T3.
      i T1 ≠ T2 and T1 ≠ T3.

      References

        • Micha R.
        • Penalvo J.L.
        • Cudhea F.
        • Imamura F.
        • Rehm C.D.
        • Mozaffarian D.
        Association between dietary factors and mortality from heart disease, stroke, and type 2 diabetes in the United States.
        JAMA. 2017; 317: 912-924
        • Sievert K.
        • Hussain S.M.
        • Page M.J.
        • et al.
        Effect of breakfast on weight and energy intake: Systematic review and meta-analysis of randomised controlled trials.
        BMJ. 2019; 364: l42
        • Haire-Joshu D.
        • Schwarz C.
        • Budd E.
        • Yount B.W.
        • Lapka C.
        Postpartum teens’ breakfast consumption is associated with snack and beverage intake and body mass index.
        J Am Diet Assoc. 2011; 111: 124-130
        • Navarro-Gonzalez I.
        • Ros G.
        • Martinez-Garcia B.
        • Rodriguez-Tadeo A.
        • Periago M.J.
        Adherencia a la dieta mediterránea y su relación con la calidad del desayuno en estudiantes de la Universidad de Murcia.
        Nutr Hosp. 2016; 33: 390
        • Delley M.
        • Brunner T.A.
        Breakfast eating patterns and drivers of a healthy breakfast composition.
        Appetite. 2019; 137: 90-98
        • Rampersaud G.C.
        • Pereira M.A.
        • Girard B.L.
        • Adams J.
        • Metzl J.D.
        Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents.
        J Am Diet Assoc. 2005; 105: 743-760
        • Brasil, Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica
        Guia alimentar para a população brasileira. Vol 2. Ministério da Saúde, 2014
        • Ministerio de Salud de la Nacion.
        Guías Alimentarias para la Población Argentina. Ministerio de Salud de la Nación, Buenos Aires, Argentina2016
        • Gibney M.J.
        • Barr S.I.
        • Bellisle F.
        • et al.
        Towards an evidence-based recommendation for a balanced breakfast-a proposal from the International Breakfast Research Initiative.
        Nutrients. 2018; 10: 1540
        • Fisberg M.
        • Kovalskys I.
        • Previdelli A.N.
        • et al.
        Breakfast consumption habit and its nutritional contribution in Latin America: Results from the ELANS Study.
        Nutrients. 2020; 12: 2397
        • Fisberg M.
        • Kovalskys I.
        • Gomez G.
        • et al.
        Latin American Study of Nutrition and Health (ELANS): Rationale and study design.
        BMC Public Health. 2016; 16: 93
        • Moshfegh A.J.
        • Rhodes D.G.
        • Baer D.J.
        • et al.
        The US Department of Agriculture Automated Multiple-Pass Method reduces bias in the collection of energy intakes.
        Am J Clin Nutr. 2008; 88: 324-332
      1. Nutrition Data System for Research. Version 2013. Nutrition Coordinating Center; 2013.

      2. Nutrition Data System for Research. Version 2014. Nutrition Coordinating Center; 2014.

        • Kovalskys I.
        • Fisberg M.
        • Gomez G.
        • et al.
        Standardization of the food composition database used in the Latin American Nutrition and Health Study (ELANS).
        Nutrients. 2015; 7: 7914-7924
        • De Castro J.M.
        Methodology, correlational analysis, and interpretation of diet diary records of the food and fluid intake of free-living humans.
        Appetite. 1994; 23: 179-192
        • Fulgoni 3rd, V.L.
        • Keast D.R.
        • Drewnowski A.
        Development and validation of the nutrient-rich foods index: A tool to measure nutritional quality of foods.
        J Nutr. 2009; 139: 1549-1554
        • Gibney M.J.
        • Barr S.I.
        • Bellisle F.
        • et al.
        Breakfast in human nutrition: The International Breakfast Research Initiative.
        Nutrients. 2018; 10: 559-571
        • Trumbo P.
        • Schlicker S.
        • Yates A.A.
        • Poos M.
        • Food, Nutrition Board of the Institute of Medicine TNA
        Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein and amino acids.
        J Am Diet Assoc. 2002; 102: 1621-1630
        • Trumbo P.
        • Yates A.A.
        • Schlicker S.
        • Poos M.
        Dietary reference intakes: Vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc.
        J Am Diet Assoc. 2001; 101: 294-301
        • FAO
        Fats and Fatty Acids in Human Nutrition. Report of an Expert Consultation.
        Food and Agriculture Organization of the United Nations, 2010
        • WHO
        Global Action Plan for the Prevention and Control of NCDs 2013–2020.
        World Health Organization, 2013
        • WHO
        Guideline: Potassium intake for adults and children. World Health Organization.
        (Published 2012. Accessed March 9, 2020)
        • WHO
        Guideline: Sugars Intake for Adults and Children.
        World Health Organization, 2015 (9789241549028)
        • European Parliament
        European Council Regulation (EU) No. 1169/2011 of the European Parliament and of the Council of 25 October 2011 on the provision of food information to consumers.
        Official J Eur Union. 2011; L304/18: 18-63
        • Barr S.I.
        • Vatanparast H.
        • Smith J.
        Breakfast in Canada: Prevalence of consumption, contribution to nutrient and food group intakes, and variability across tertiles of daily diet quality. A study from the International Breakfast Research Initiative.
        Nutrients. 2018; 10: 985
        • Bellisle F.
        • Hebel P.
        • Salmon-Legagneur A.
        • Vieux F.
        Breakfast consumption in French children, adolescents, and adults: A nationally representative cross-sectional survey examined in the context of the International Breakfast Research Initiative.
        Nutrients. 2018; 10: 1056
        • Drewnowski A.
        • Rehm C.D.
        • Vieux F.
        Breakfast in the United States: Food and nutrient intakes in relation to diet quality in National Health and Examination Survey 2011-2014. A study from the International Breakfast Research Initiative.
        Nutrients. 2018; 10: 1200
        • Fagt S.
        • Matthiessen J.
        • Thyregod C.
        • Korup K.
        • Biltoft-Jensen A.
        Breakfast in Denmark. Prevalence of consumption, intake of foods, nutrients and dietary quality. A study from the International Breakfast Research Initiative.
        Nutrients. 2018; 10: 1085
        • Gaal S.
        • Kerr M.A.
        • Ward M.
        • McNulty H.
        • Livingstone M.B.E.
        Breakfast consumption in the UK: Patterns, nutrient intake and diet quality. A study from the International Breakfast Research Initiative Group.
        Nutrients. 2018; 10: 999
        • Ruiz E.
        • Avila J.M.
        • Valero T.
        • Rodriguez P.
        • Varela-Moreiras G.
        Breakfast consumption in Spain: Patterns, nutrient intake and quality. Findings from the ANIBES Study, a study from the International Breakfast Research Initiative.
        Nutrients. 2018; 10: 1324
        • DHHS-USDA
        What we eat in America data tables. Nutrient intakes: From foods/beverage.
        (Updated 2019. Accessed March 9, 2020)
      3. IBM SPSS Statistics for Windows. Version 22. IBM Corp; 2013.

        • Institute of Medicine
        Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids.
        The National Academies Press, 2005 (978-0-309-08525-0)
        • Barr S.I.
        • DiFrancesco L.
        • Fulgoni 3rd, V.L.
        Consumption of breakfast and the type of breakfast consumed are positively associated with nutrient intakes and adequacy of Canadian adults.
        J Nutr. 2013; 143: 86-92
        • Barr S.I.
        • DiFrancesco L.
        • Fulgoni 3rd, V.L.
        Breakfast consumption is positively associated with nutrient adequacy in Canadian children and adolescents.
        Br J Nutr. 2014; 112: 1373-1383
        • Pereira J.L.
        • Castro M.A.
        • Hopkins S.
        • Gugger C.
        • Fisberg R.M.
        • Fisberg M.
        Prevalence of consumption and nutritional content of breakfast meal among adolescents from the Brazilian National Dietary Survey.
        J Pediatr (Rio J). 2018; 94: 630-641
        • Movassagh E.Z.
        • Baxter-Jones A.D.G.
        • Kontulainen S.
        • Whiting S.J.
        • Vatanparast H.
        Tracking dietary patterns over 20 years from childhood through adolescence into young adulthood: The Saskatchewan Pediatric Bone Mineral Accrual Study.
        Nutrients. 2017; 9: 990-1004
        • World Bank
        Urban population (% of total population).
        in: World Development Indicators. The World Bank, Washington, DC2015
        • Gibson R.S.
        • Charrondiere U.R.
        • Bell W.
        Measurement errors in dietary assessment using self-reported 24-hour recalls in low-income countries and strategies for their prevention.
        Adv Nutr. 2017; 8: 980-991
        • Gibson R.S.
        Principles of Nutritional Assessment.
        2nd ed. University Press, 2005

      Biography

      I. Kovalskys is an associate professor, Facultad de Ciencias Médicas, Pontificia Universidad Católica, Buenos Aires, Argentina.
      M. Fisberg is a coordinator, Excellence Center for Nutrition and Feeding Difficulties (CENDA-PENSI Institute), Jose Luiz Egydio Setubal Foundation, and an associate professor, Departamento de Pediatria, Universidade Federal de São Paulo, both in São Paulo, Brazil.
      A. N. Previdelli, is a professor, Faculdade de Ciências Biológicas e da Saúde, Universidade São Judas Tadeu, São Paulo, Brazil.
      J. L. Pereira is a postdoctoral fellow, Faculdade de Saúde Pública, Departmento de Nutrição, Universidade de São Paulo, São Paulo, Brazil.
      I. Z. Zimberg is a researcher, Departamento de Psicobiologia, Universidade Federal de São Paulo, São Paulo, Brazil.
      V. Guajardo is a professor, Facultad de Ciencias Médicas, Pontifica Universidad Católica, Buenos Aires, Argentina.
      R. Fisberg is an associate professor, Faculdade de Saúde Pública, Departmento de Nutrição, Universidade de São Paulo, São Paulo, Brazil.
      G. Ferrari is an associate professor, Laboratorio de Ciencias de la Actividad Física, el Deporte y la Salud, Facultad de Ciencias Medicas, Universidad de Santiago de Chile, USACH, Santiago, Chile and a researcher, Laboratorio de Rendimiento Humano, Grupo de Estudio en Educacion, Actividad Fisica y Salud (GEEAFyS), Universidad Catolica del Maule, Talca, Chile.
      G. Gómez is an associate professor, Departamento de Bioquímica, Escuela de Medicina, Universidad de Costa Rica, San José, Costa Rica.
      A. Rigotti is an associate professor, Centro de Nutrición Molecular y Enfermedades Crónicas, Departamento de Nutrición, Diabetes y Metabolismo, Escuela de Medicina, Pontificia Universidad Católica, Santiago, Chile.
      L. Y. Cortés Sanabria is an associate professor, Departamento de Nutrición y Bioquímica, Pontificia Universidad Javeriana, Bogotá, Colombia.
      M. C. Yépez García is an associate professor, Colégio de Ciencias de la Salud, Universidad San Francisco de Quito, Quito, Ecuador.
      M. Herrera-Cuenca is an associate professor, Centro de Estudios del Desarrollo, Universidad Central de Venezuela (CENDES-UCV)/Fundación Bengoa, Caracas, Venezuela.
      M. R. Liria Domínguez is an adjunct researcher, Instituto de Investigación Nutricional, La Molina, Lima, Peru.