Original Article

Yonago Acta medica 2016;59:55–60

Skipping Breakfast and Risk of Mortality from Cancer, Circulatory Diseases and
All Causes: Findings from the Japan Collaborative Cohort StudyYae Yokoyama,*† Kazunari Onishi,* Takenobu Hosoda,‡ Hiroki Amano,* Shinji Otani,§ Youichi Kurozawa* andAkiko Tamakoshi||*Division of Health Administration and Promotion, Department of Social Medicine, School of Medicine, Tottori University Faculty of
Medicine, Yonago 683-8503, Japan, †Tottori College, Kurayoshi 682-8555, Japan, ‡Tottori College of Nursing, Kurayoshi 682-8555,
Japan, §International Platform for Dryland Research and Education, Tottori University, Tottori 680-0001, Japan and ||Department of
Public Health, Hokkaido University Graduate School of Medicine, Sapporo 060-8638, Japan

ABSTRACT

circulatory diseases and all causes among men and allcauses mortality among women in Japan.

Background

Breakfast eating habits are a dietary
pattern marker and appear to be a useful predictor ofa healthy lifestyle. Many studies have reported the unhealthy effects of skipping breakfast. However, there arefew studies on the association between skipping breakfast and mortality. In the present study, we examined theassociation between skipping breakfast and mortality
from cancer, circulatory diseases and all causes using
data from a large-scale cohort study, the Japan Collaborative Cohort Study (JACC) Study.
Methods A cohort study of 34,128 men and 49,282
women aged 40–79 years was conducted, to explore theassociation between lifestyle and cancer in Japan. Participants completed a baseline survey during 1988 to 1990
and were followed until the end of 2009. We classified
participants into two groups according to dietary habitswith respect to eating or skipping breakfast and carriedout intergroup comparisons of lifestyle. Multivariate
analysis was performed using the Cox proportional hazard regression model.
Results There were 5,768 deaths from cancer and 5,133
cases of death owing to circulatory diseases and 17,112
cases for all causes of mortality during the median 19.4
years follow-up. Skipping breakfast was related to unhealthy lifestyle habits. After adjusting for confounding
factors, skipping breakfast significantly increased therisk of mortality from circulatory diseases [hazard ratio(HR) = 1.42] and all causes (HR = 1.43) in men and allcauses mortality (HR = 1.34) in women.
Conclusion Our findings showed that skipping breakfast is associated with increasing risk of mortality from

Key words cancer; circulatory diseases; mortality;
skipping breakfast; prospective study

It has been widely propounded that breakfast is themost important meal of the day.1–4 Various studies havereported that skipping breakfast is related to weight
gain,5, 6 dyslipidemia,7, 8 hypertension,9 insulin sensitivity and diabetes mellitus7, 8, 10 and coronary heart disease.11 However, there are few studies on the association
between skipping breakfast and mortality.
Eating breakfast was associated with physical healthstatus and mortality in a pioneer longitudinal study initiated in 1965 in Alameda County, California in the United States.13 In that study, multivariate analysis, including
confounding factors, was not done because of the relatively low number of deaths among the study population.12 Later, multivariate analysis of data from the Alameda County study showed that skipping breakfast was
associated with an increased risk of total mortality.13
The association between skipping breakfast and causesof death has not been clarified. Therefore, in the present
study, multivariate analysis of data from a large-scalecohort study in Japan was carried out, to investigate theassociation between skipping breakfast and mortality
from cancer, circulatory diseases and all causes.
MATERIALS AND METHODSJACC StudyThe Japan Collaborative Cohort (JACC) Study for
Evaluation of Cancer Risks, sponsored by the Ministryof Education, Sports, Science, and Technology of Japan,
began between 1988 and 1990 and enrolled participants
living in 45 areas throughout Japan. A total of 110,585
participants (46,395 men and 64,190 women) aged
40–79 years completed self-administered questionnaires
about their lifestyles and medical histories. Informed
consent was obtained from all participants prior to

Corresponding author: Yae Yokoyamayaeyae@ns.cygnus.ac.jp
Received 2015 December 9
Accepted 2016 January 4
Abbreviations: BMI, body mass index; CI, confidence interval;
FFQ, food frequency questionnaire; HR, hazard ratio; ICD-10, theinternational classification of diseases; JACC Study, the Japan Collaborative Cohort Study55

Y. Yokoyama et al.

completion of the questionnaire. Sampling methods andother details of the JACC study have been described
elsewhere.14, 15
Participants with a previous medical history of any
cancer, stroke, or myocardial infarction at the baseline
survey were excluded (n = 4,407; 1,817 men and 2,590
women). Additionally, participants were excluded who
died within 5 years (n = 3,609; 2,228 men and 1,381
women) after the baseline survey and those who did not
answer questions regarding their breakfast eating habits (n = 19,159; 8,222 men and 10,937 women). A total
83,410 participants (34,128 men and 49,282 women)
were finally enrolled for the study. The study design andinformed consent procedure were approved by the Ethics Review Committee of Nagoya University School of
Medicine.

was classified as regular time from five to eight p.m. andirregular time other than that.
Questionnaire on lifestyle

A broad set of potential confounding factors were determined from additional data obtained at baseline. These
included age, sex, history of hypertension (yes or no)
and history of diabetes mellitus (yes or no). Body massindex (BMI) was calculated as weight (kg) divided by
the square of height (m2). Smoking status was classified
into three categories: current smoker, past smoker, or
never smoked. Alcohol status was classified into three
categories: current alcohol use, past alcohol use andnever consumed alcohol. Education level was assessedand classified into two categories: college level or higher
and less than college level. The number of hours engaged in leisure-time physical activity was classified into
3 h or more per week or less than 3 h per week. Walking duration was classified as 60 min or more per day orless than 60 min per day. Sleep duration was assessedand classified into three categories: < 5 h, 5–9 h, and >9 h. Marital status was classified as married, widowed,
divorced and single. Participants were then reclassified
into two groups, married or unmarried (including widowed, divorced and single). Work schedule was categorized as follows: day shift, night shift, or shift work.

Mortality surveillance

Mortality surveillance was conducted by systematicallyreviewing death certificates, which were forwarded by
the centers serving participants who had died. Mortality
data were then centralized at the Ministry of Health andWelfare, and the underlying causes of death coded for
National Vital Statistics according to the International
Classification of Diseases, 10th Revision (ICD-10).
Participants were followed until death or throughthe end of 2009, except in 10 areas: participants were
followed to the end of 1999 in four areas, to the end of
2003 in four areas, and to the end of 2008 in two areas.
Deaths from cancer were classified as ICD-10 codes
C00-C97, and deaths from circulatory diseases as codes
I00-I99.

Statistical analysis

First, baseline characteristics were categorized according to breakfast status using means (standard deviation)and proportions. To clarify the associations between
breakfast status and potential confounders, we calculated the age adjusted proportions for each factor andanalyzed the associations using multiple logistic regression. Finally, the multivariate Cox proportional hazards
model by SAS PHREG with strata statement (differenceof areas) was used to estimate hazard ratios (HR) and
95% confidence intervals (CIs) of mortality associatedwith skipping breakfast. HR1 of the multivariate model
was adjusted for age. HR2 was adjusted for age, history of hypertension, history of diabetes mellitus, BMI,
smoking status, alcohol status, education level, physicalactivity, walking duration, sleep duration, marital status
and work schedule. There was no evidence that proportional hazard assumptions were violated. All statisticalanalyses were conducted using Statistical Analysis System version 9.1 software (SAS Institute, Cary, NC).

Questionnaire on dietary habits

Information about dietary habits was obtained using aself-administered questionnaire. The type of breakfast
consumed was assessed according to the following fivecategories: Japanese style, Western style, Chagayu style(tea rice gruel) and no or nearly no breakfast eaten andothers. We reclassified participants into two groups,
as those who eat breakfast [including Japanese style,Western style, Chagayu style (tea rice gruel) and others]
and those who skip breakfast (no or nearly no breakfast
eaten). Total energy intake was estimated using a foodfrequency questionnaire (FFQ). The reproducibility andvalidity of the dietary questionnaire have been reported
elsewhere.16, 17 The frequency of snacking was assessedusing the following five categories: almost never, 1–2
times per month, 1–2 times per week, 3–4 times per
week, and almost every day. Participants were then reclassified into two groups, as those who snacked every
day and those who did not snack every day. Dinner time

RESULTSThe baseline characteristics of participants according to
breakfast status are shown in Table 1. Participants who
skipped breakfast were significantly younger than those56

Skipping breakfast and risk of mortality
Table 1. Baseline characteristics of demographic by breakfast status, 1988–1990, JACC Study
Men
Eating breakfast* Skipping breakfast† P value‡
Number of subjects
33,0391,089
Person years
550,548
17,880Age, y (mean ± SD)
56.0 ± 10.0
50.0 ± 9.0< 0.0001
40–49, n
8,875
620
50–59, n
10,318292
60–69, n
9,908
137
70–79, n3,93840
History of hypertension, %17.7
160.0669
History of diabetes mellitus, %5.5
4.4
0.05440.8988
Body mass index, kg/m2, %< 18.5
9.7
12.6
18.5 = < and < 25.0
72.6
68.9
25.0 = <17.7
19.5
Smoking status, %< 0.0001
Current
53.3
71.0
Past
25.3
16.7
Never
21.4
12.3
Alcohol status, %< 0.0001
Current
76.2
69.5
Past
5.5
7.3
Never
18.3
24.2
Education level, %0.136
College and more
14.4
15.9
Physical activity, %0.005
3 h = < /week
14.6
10.6
Walking duration, %< 0.0001
60 min = < /day
50.5
41.4
Sleep duration, %0.1906<5h4.0
4.6
5 h = < and < 9 h
85.2
87.6
>9h
10.8
7.8
Marital status, %< 0.0001
Married
94.2
86.4
Work schedule, %< 0.0001
Day shift
84.7
76.9
Night shift
5.1
5.0
10.2
18.1
Shift work (day and night shift)
Total energy intake, kcal/day
1,756.4 ± 491.1
1,476.4 ± 422.3< 0.0001
Dinner time, %< 0.0001
Irregurar
3.1
11.0
Frequency of snack, %0.0032
Everyday
12.0
13.5

Women
Eating breakfast* Skipping breakfast† P value‡
48,1891,093
815,168
18,69857.5 ± 10.0
51.6 ± 8.8< 0.0001
11,893536
15,267359
14,831
150
6,198
48
19.9
19.2
0.46763.4
3.8
0.57560.0827
11.7
14.7
67
61.9
21.3
23.4
< 0.0001
4.7
22.1
1.4
4.6
94.9
73.3
< 0.0001
23.1
32.0
4.3
4.3
72.5
63.7
0.62658.4
9.4
0.000310.0
6.8< 0.0001
51.8
44.1
0.003
5.5
8.2
88.2
86.9
6.3
4.9
< 0.0001
96.7
97.9< 0.0001
90.7
78.6
2.5
9.4
6.8
12.0
1,444.2 ± 363.0
1,193.1 ± 327.8< 0.0001< 0.0001
1.8
5.8< 0.0001
17.3
18.9

Values were reported as number, mean (standard deviation) or percentage.
All proportions of potential confounding factors were age adjusted.
*Breakfast eating was defined as those having breakfast style of “Japanese style” or “Western style” or “Chagayu style (tea rice gruel)” or“others.”†Breakfast skipping was defined as those having breakfast style of “no or nearly no breakfast eaten.”‡Analyzed using multiple logistic regression except for means of age (t-test).

57

Y. Yokoyama et al.
Table 2. The number of death, HRs and 95% CIs for mortalities from cancer, circulatory diseases and all causesby breakfast status, 1988–2009, JACC Study
Cause of death
Cancer mortality
n of deaths
HR1 * (95% CI)
HR2 † (95% CI)
Circulatory diseases mortality
n of deaths
HR1* (95% CI)
HR2† (95% CI)
All causes mortality
n of deaths
HR1 * (95% CI)
HR2 † (95% CI)

Men
Eating breakfast‡ Skipping breakfast§ P value
3,394
1.0
1.0

86
1.35 (1.08–1.67)
1.27 (0.98–1.65)

2,517
1.0
1.0
9,180
1.0
1.0

Women
Eating breakfast‡ Skipping breakfast§ P value

0.00720.0741

2,246
1.0
1.0

42
1.26 (0.93–1.72)
1.30 (0.87–1.94)

0.13630.189052
1.48 (1.13–1.96)
1.42 (1.02–2.02)

0.00520.0485

2,532
1.0
1.0

32
1.21 (0.85–1.71)
1.19 (0.71–1.05)

0.29010.1828219
1.51 (1.32–1.73)
1.43 (1.21–1.69)< 0.0001< 0.0001

7,596
1.0
1.0

117
1.32 (1.32–1.59)
1.34 (1.04–1.73)

0.00260.0234*HR1: Adjusted for age.
†HR2: HR1 + history of hypertention, history of diabetes mellitus, body mass index, smoking status, alcohol status, education level, physical activity, walking duration, sleep duration, marital status and work schedule.
‡Breakfast eating was defined as those having breakfast style of “Japanese style” or “Western style” or “Chagayu style (tea rice gruel)” or“others.”§Breakfast skipping was defined as those having breakfast style of “no or nearly no breakfast eaten.”CI, confidence interval; HR, hazard ratio; JACC Study, the Japan Collaborative Cohort Study.

who did not. In men, breakfast status were associatedwith following confounding factor: smoking status, alcohol status, physical activity, walking duration, marital
status, work schedule, total energy intake, dinner time,
frequency of snack. In women, breakfast status wereassociated with following confounding factor: smoking
status, alcohol status, physical activity, walking duration,
sleep duration, marital status, work schedule, total energy intake, dinner time, frequency of snack. There wasno difference in the proportion of BMI.
There were a total 9,399 deaths among men and 7,713
among women during the median 19.4 years follow-up:
cancer deaths comprised 3,480 among men and 2,288
among women and circulatory diseases accounted for
2,569 deaths among men and 2,564 among women. The
number of death, HRs and 95% CIs for mortalities fromcancer, circulatory diseases and all causes by breakfast
status are shown in Table 2. Age-adjusted HRs of theparticipant group that reported skipping breakfast weresignificantly higher than those who ate breakfast,: forcancer among men (HR = 1.35, 95% CI 1.08–1.67, P =0.0072) and circulatory diseases among men (HR = 1.48,
95% CI, 1.13–1.96, P = 0.0052) and all causes mortality
among men (HR = 1.51, 95% CI 1.32–1.73, P < 0.0001)
and women (HR = 1.32, 95% CI 1.32–1.59, P < 0.0026).
Multivariate HRs of the group that skipped breakfast
were significantly higher than those who ate breakfast,

for mortality from circulatory diseases among men (HR= 1.42, 95% CI, 1.02–2.02, P = 0.0485) and all causes
among men (HR = 1.43, 95% CI 1.21–1.69, P < 0.0001)
and women (HR = 1.34, 95% CI 1.04–1.73, P = 0.0234).
In addition, skipping breakfast tended to be associatedwith cancer mortality among men (HR = 1.27, 95% CI,
0.98–1.65, P = 0.0741).
DISCUSSION
In the present study, participants who skipped breakfast
had unhealthy lifestyle such as current smoker, physicalactivity less than 3 h per a week, walking duration lessthan 60 min per a day, low levels of total energy intake,eating dinner at irregular time and snacking every day.
These findings support the notion that breakfast-eating
habits are a dietary pattern marker3, 4 that is a usefulpredictor of a healthy lifestyle.18–20 Skipping breakfast
was also related to sleep duration, marital status has a
spouse and shift work. The multivariate models were
adjusted for these confounding factors and known risk
factors of lifestyle-related diseases. Our study represents
the first investigation of an association between skipping
breakfast and multivariate-adjusted mortality owing tolifestyle-related diseases including cancer and circulatory diseases. Skipping breakfast was associated withincreasing risk of mortality from circulatory diseases
and all causes in men and all causes mortality in wom58

Skipping breakfast and risk of mortality

en. Factors such as time of eating dinner and frequency
of snacking had a large number of missing values. We
added each of them to the models. The results were notaffected.
Concerning the timing of meals, deviation of breakfast time leads to a disturbance of the phase peak of
the clock gene, resulting in an inability to entrain to theday/night cycle and finally, disturbance of the circadianrhythm in experiments of mice.23, 24 Disturbance ofthe circadian rhythm may cause a reduction in exercise capacity, glucose tolerance disorder and metabolic
disorder, which is associated with obesity and various
lifestyle diseases.25–27 Furthermore these mechanisms
may lead to increasing risk of mortality from circulatory
diseases and all causes.
Recently, a large prospective study of middle-aged
or older man health professionals in the United Statesfound that skipping breakfast increased the risk of coronary heart disease.11 That study suggested that the timing of meals might be directly responsible for metabolic
effects, or alternatively, that breakfast consumption isa marker for an appropriate dietary pattern in terms of
dietary fiber, macronutrients and micronutrients, particularly if breakfast cereals are included in the meal,or late night snack high in energy. Skipping breakfast
has been reported to impair postprandial insulin sensitivity and fast lipids and could lead to weight gain in a
multiple randomized crossover trial.7 In addition, somestudies have indicated that a regular diet suppresses dietinduced obesity.21, 22 These studies support our resultswith regard to skipping breakfast and mortality fromcirculatory diseases.
The influence of the circadian rhythm on dietary
habit, such as combination of nutrients and foods, nutrient balance, daily meal rhythm (time of eating, numberof times, distribution rate, starvation interval and snack),
marital status, shift work, sleep duration and its relationship with mortality risk requires further analysis.
Our study showed that skipping breakfast tended tobe related to cancer mortality. Some kinds of cancers are
known to be associated with lifestyle, including dietary
habits. According to the World Health Organization’s(WHO) International Agency for Research on Cancer(IARC), human epidemiologic evidence suggests thatcircadian disruption brought on by shift work is most
likely carcinogenic to humans (IARC classification,
Group 2A).28 Therefore, the timing of meals related tocircadian rhythm may be associated with some kinds ofcancers. Further study is needed of the associations between skipping breakfast and different cancers.
The present study has some limitations. The baseline survey was conducted in 1988 to 1990 and eating

habits were queried only once. Lifestyles have changed
in Japan since the time of the survey. According to recent data in Japan, trends in the percentage of subjects
who skipped breakfast increased from 7.9% in 1990 to
11.4% in 2013.29 The participants enrolled in the present
study were aged 40–79 years and the rate of skipping
breakfast was 2.0%. Therefore, our findings may vary
among young people. Moreover, our study did not include other dietary confounding factors, such as nutrient
intake, because the number of participants who skippedbreakfast was too small to calculate these.
In conclusion, this study showed that skipping
breakfast is associated with a risk of mortality fromcirculatory diseases and all causes among men and allcauses mortality among women. In addition, skipping
breakfast was found to be related to unhealthy lifestyle
habits such as current smoker, physical activity less than
3 h per a week, walking duration less than 60 min per
a day, low levels of total energy intake, eating dinner at
irregular time and snacking every day. The findings ofthe present study may provide evidence to support therecommendation to eat breakfast daily, so as to prevent
lifestyle-related diseases and improve overall health.
Acknowledgments: We wish to express our sincere thanks to thepresent members of the JACC Study Group: Dr. Akiko Tamakoshi(present chairperson of the study group), Hokkaido University
Graduate School of Medicine; Drs. Mitsuru Mori and Fumio
Sakauchi, Sapporo Medical University School of Medicine;Dr. Yutaka Motohashi, Akita University School of Medicine;Dr. Ichiro Tsuji, Tohoku University Graduate School of Medicine;Dr. Yoshikazu Nakamura, Jichi Medical School; Dr. Hiroyasu Iso,
Osaka University School of Medicine; Dr. Haruo Mikami, Chiba
Cancer Center; Dr. Michiko Kurosawa, Juntendo University Schoolof Medicine; Dr. Yoshiharu Hoshiyama, Yokohama Soei University; Dr. Naohito Tanabe, University of Niigata Prefecture; Dr. Koji
Tamakoshi, Nagoya University Graduate School of Health Science;
Dr. Kenji Wakai, Nagoya University Graduate School of Medicine;
Dr. Shinkan Tokudome, National Institute of Health and Nutrition; Dr. Koji Suzuki, Fujita Health University School of Health
Sciences; Dr. Shuji Hashimoto, Fujita Health University School of
Medicine; Dr. Shogo Kikuchi, Aichi Medical University School of
Medicine; Dr. Yasuhiko Wada, Faculty of Nutrition, University ofKochi; Dr. Takashi Kawamura, Kyoto University Center for Student
Health; Dr. Yoshiyuki Watanabe, Kyoto Prefectural University of
Medicine Graduate School of Medical Science; Dr. Kotaro Ozasa,
Radiation Effects Research Foundation; Dr. Tsuneharu Miki, Kyoto
Prefectural University of Medicine Graduate School of Medical
Science; Dr. Chigusa Date, School of Human Science and Environment, University of Hyogo; Dr. Kiyomi Sakata, Iwate Medical
University; Dr. Youichi Kurozawa, Tottori University Faculty of
Medicine; Drs. Takesumi Yoshimura and Yoshihisa Fujino, University of Occupational and Environmental Health; Dr. Akira Shibata,
Kurume University; Dr. Naoyuki Okamoto, Kanagawa Cancer Center; and Dr. Hideo Shio, Moriyama Municipal Hospital. We thankall staff members involved in this study for their valuable help in
conducting the baseline survey and follow-up. This work was supported by Grants-in-Aid for Scientific Research from the Ministryof Education, Science, Sports, and Culture of Japan (Monbusho),Grants-in-Aid for Scientific Research on Priority Areas of Cancer, and Grants-in-Aid for Scientific Research on Priority Areasof Cancer Epidemiology from the Japanese Ministry of Education, Culture, Sports, Science, and Technology (Monbu-Kagaku-59

Y. Yokoyama et al.
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The authors declare no conflict of interest.

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