pebo
Belief beyond the evidence: using the proposed effect of breakfast
on obesity to show 2 practices that distort scientific evidence1–4
Andrew W Brown, Michelle M Bohan Brown, and David B Allison
ABSTRACT
Background: Various intentional and unintentional factors influ-
ence beliefs beyond what scientific evidence justifies. Two such
factors are research lacking probative value (RLPV) and biased
research reporting (BRR).
Objective: We investigated the prevalence of RLPV and BRR in
research about the proposition that skipping breakfast causes weight
gain, which is called the proposed effect of breakfast on obesity
(PEBO) in this article.
Design: Studies related to the PEBO were synthesized by using
a cumulative meta-analysis. Abstracts from these studies were also
rated for the improper use of causal language and biased interpre-
tations. In separate analyses, articles that cited an observational
study about the PEBO were rated for the inappropriate use of causal
language, and articles that cited a randomized controlled trial (RCT)
about the PEBO were rated for misleadingly citing the RCT.
Results: The current body of scientific knowledge indicates that the
PEBO is only presumed true. The observational literature on the PEBO
has gratuitously established the association, but not the causal
relation, between skipping breakfast and obesity (final cumulative
meta-analysis P value ,10242), which is evidence of RLPV. Four
examples of BRR are evident in the PEBO literature as follows: 1)
biased interpretation of one’s own results, 2) improper use of causal
language in describing one’s own results, 3) misleadingly citing
others’ results, and 4) improper use of causal language in citing others’
work.
Conclusions: The belief in the PEBO exceeds the strength of
scientific evidence. The scientific record is distorted by RLPV
and BRR. RLPV is a suboptimal use of collective scientific re-
sources. Am J Clin Nutr 2013;98:1298–308.
INTRODUCTION
Some beliefs about scientific topics are held true despite evi-
dence refuting them, whereas other science-related beliefs are
presumed true even though insufficient evidence exists to support
or refute them (1). One such presumption is that regularly con-
suming compared with skipping breakfast protects against obesity
or causes weight loss, which we refer to as the proposed effect of
breakfast on obesity (PEBO)5 in this article. More precisely, the
PEBO goes beyond indicating an association between skipping
breakfast and obesity (in which breakfast consumption and lower
weight are observed together) by indicating that the introduction
of breakfast causes a decrease in body weight. We have chosen
the PEBO as an example because 1) it is a topic that is amenable
to conducting randomized controlled trials (RCTs), and thus,
1298 Am J Clin Nutr 2013;98:1298–308. Printed in USA. Ó 2013 American Society for Nutrition
there are not insurmountable barriers to moving beyond obser-
vational evidence, and 2) it seems like a less politically charged
topic than the topics of some previous publications on biased
reporting [eg, sugar-sweetened beverages (2, 3) and breastfeeding
(4)] to better facilitate the discussion of extrascientific factors that
affect the fidelity of research reporting.
In this article, we first establish that the PEBO is only a pre-
sumption so that we can examine 2 factors that may influence the
Downloaded from ajcn.nutrition.org by guest on April 30, 2016
propensity to believe in a presumption beyond the available evi-
dence. The first factor we identified is research lacking probative
value (RLPV), which we defined as experiments or analyses that
are 1) about questions that have already been sufficiently an-
swered or 2) designed in such a way that they cannot advance the
scientific knowledge about the question. As an example, when no
association studies existed about the PEBO, the first few studies
were certainly probative. Similarly, the first few studies to show
the association in children compared with adults may be con-
sidered probative. However, at some point, additional similar
observational analyses will only trivially add to our knowledge
regarding the PEBO by studying nonmeaningfully different sub-
groups or by gratuitously replicating existing associations. We
quantified RLPV by conducting a cumulative meta-analysis to
show that the association, but not the causal relation, between
breakfast and obesity has been more than sufficiently established.
The second factor was biased research reporting (BRR). We
looked at 4 indications of BRR: 1) biased interpretation of one’s
own results, 2) improper use of causal language in describing
one’s own results, 3) misleadingly citing others’ results, and 4)
improper use of causal language in citing others’ work. By
discussing RLPV and BRR, we hope that 1) future efforts will be
spent on elucidating novel associations and causal relations by
1
From the Office of Energetics (AWB and DBA), the Nutrition Obesity
Research Center (AWB, MMBB, and DBA), the School of Public Health
(AWB and DBA), and the Department of Nutrition Sciences (MMBB and
DBA), University of Alabama at Birmingham, Birmingham, AL.
2
Views expressed in this article are those of the authors and do not nec-
essarily represent those of the NIH or any other organization.
3
Supported by the National Institute of Diabetes and Digestive and Kid-
ney Diseases (NIDDK P30DK056336 and NIDDK T32DK62710).
4
Address correspondence to DB Allison, RPHB 140J, 1530 Third Avenue
South, Birmingham, AL 35294-0022. E-mail: dallison@uab.edu.
5
Abbreviations used: BRR, biased research reporting; NWCR, National
Weight Control Registry; PEBO, proposed effect of breakfast on obesity;
RCT, randomized controlled trial; RLPV, research lacking probative value.
Received April 15, 2013. Accepted for publication August 20, 2013.
First published online September 4, 2013; doi: 10.3945/ajcn.113.064410.
 BREAKFAST, OBESITY, AND BIAS
conducting probative research, 2) future research results will be
reported with greater fidelity by minimizing BRR, and 3) the
belief in scientific topics will be grounded in scientific evidence.
METHODS
Establishing that the PEBO is a widely believed
presumption
Lay-media, scientific, and government sources were searched
for statements about breakfast and obesity to establish that the
PEBO is widely believed. To evaluate our perception that the
PEBO is only a presumption rather than an empirically supported
scientific conclusion, scientific databases were searched for
empirical human research about the PEBO. In addition, studies
were reviewed from one published meta-analysis and 3 sys-
tematic reviews (5–8).
Cumulative meta-analysis to assess RLPV
We identified 92 unique articles about the PEBO that were
cited in one published meta-analysis and 3 published systematic
reviews (5–8). Briefly, Horikawa et al (5) meta-analyzed 19
studies of the association between breakfast consumption and
odds of being overweight or obese in Asian and Pacific coun-
tries. Szajewska and Ruszczy nski (8) systematically reviewed
studies of children and adolescents in Europe and identified 16
studies. Mesas et al (6) systematically reviewed a number of
eating behaviors related to obesity and reported 69 articles that
looked at breakfast and obesity in English, Spanish, or Portu-
guese. Rampersaud et al (7) identified 16 articles in children and
adolescents in a systematic manner, although the review was not
declared a systematic review. All identified studies were ob-
servational. Studies were synthesized in a manner similar to the
breakfast-obesity meta-analysis by Horikawa et al (5) as fol-
lows: breakfast consumption in each article had to be defined as
a frequency (as opposed to investigating only the type or amount
of breakfast consumed); the breakfast skipping group “was de-
fined as the lowest category of breakfast frequency in an in-
dividual study” (5); body weight needed to be classified into
overweight and/or obese; and analyses that adjusted for potential
confounders were selected when available and appropriate. In
addition, studies that considered both overweight and obese
were included; mutually exclusive groups (eg, male and female
subjects) were included as separate groups for analysis where
possible and appropriate; and we limited the analysis only to full
articles in the English language. SEs and ORs were calculated
for each independent study group. In total, 58 of 92 studies fit
these criteria with a total of 88 independent OR estimates. With
the use of a random-effects model in Review Manager 5.1
software (The Nordic Cochrane Centre, The Cochrane Collab-
oration), we first synthesized all data by weighting each study
group by the inverse variance of its point estimate. As a check,
this method successfully reproduced the results of Horikawa
et al (5) when limited only to data in their analysis (OR: 1.75;
CI: 1.57, 1.95). Evidence of funnel-plot asymmetry was assessed
graphically and by using Egger’s linear regression (9). Funnel-plot
asymmetry can be indicative of a publication bias or unaccounted
heterogeneity in the analysis. Subsequently, we conducted a cu-
mulative meta-analysis by sequentially synthesizing point estimates
1299
from the meta-analysis by publication year starting from 1994
and ending in 2011. All studies published within a given year were
added concurrently.
Assessing BRR
For all ratings, AWB and MMBB independently rated the
articles with input from DBA on the rating scales and criteria. All
rating disagreements were settled by consensus between AWB
and MMBB.
1) Biased interpretation of one’s own results. Of the 92
articles identified for the cumulative meta-analysis, 88
articles contained abstracts indexed in PubMed in En-
glish. The results and conclusions stated in these ab-
stracts were rated as follows: either not mentioning
breakfast in relation to obesity (none) or indicating that
breakfast was beneficial (positive), there was no relation
between breakfast and obesity (no relation), breakfast
was detrimental (negative), or the relation between
breakfast and obesity was mixed (mixed). Although
Downloaded from ajcn.nutrition.org by guest on April 30, 2016
some studies implied mixed results (eg, breakfast was
only stated as significant in one group and not mentioned
in the other group), results were rated only on explicit
mentioning of breakfast and obesity to allow reasonable
tolerance for word limitations of abstracts.
2) Improper use of causal language in describing one’s own
results. The 88 rated abstracts were from observational
studies; 76 studies were cross-sectional, 11 studies were
longitudinal, and one study was a case-control study.
Therefore, language concluding a finding of cause and
effect was not appropriate within these 88 abstracts. Con-
clusions that included breakfast and obesity were subse-
quently rated causal if causal language was used or
associative if the inference was limited to associations.
In addition, conclusions were rated qualified causal if
qualifiers such as “may” or “suggests” were included in
the causal language because distinguishing between state-
ments that used qualifiers to introduce a hypothesis com-
pared with veiling a causal statement was subjective.
3) Misleadingly citing others’ results. We examined the man-
ner in which articles cited an RCT reported by Schlundt
et al (10). Schlundt et al (10) assigned women to a weight-
loss plan that included or excluded breakfast and stratified
them by prestudy habitual breakfast intake for a total of 4
study groups. They noted a P value ,0.06 for the interac-
tion of breakfast habit by breakfast assignment, with no
significant main effect of breakfast consumption, which
indicated that subjects who were assigned to change from
their baseline breakfast frequency lost more weight than
did subjects assigned to continue their baseline breakfast
frequency (Table 1). We identified a total of 91 English-
language articles that cited Schlundt et al (10) by searching
the Web of Science (http://apps.webofknowledge.com) and
Scopus (http://www.scopus.com) on 14 May 2012. Scopus
contains citation records back to 1996; the Web of Science
subscription for the University of Alabama at Birmingham
is current from 1990 to year end 2011. We selected this
article because 1) it was fairly well cited, and 2) the study
1300 BROWN ET AL
TABLE 1
Weight-loss results from Schlundt et al (10)1
Baseline breakfast habits
Eaters Skippers Total
Assignment (kg)
Breakfast 6.2 6 3.3 [15]2 7.7 6 3.3 [8] 6.73
No breakfast 8.9 6 4.2 [14] 6.0 6 3.9 [8] 7.8
Total 7.5 6.9 —
1
No main effects between the 2 factors were noted, but an interaction
effect was noted at P , 0.06. Adapted with permission from reference
10.
2
Mean 6 SD; n in brackets (all such values).
3
Mean (all such values).
had mixed results, which allowed us to potentially observe
misleading citations both for and against breakfast. Arti-
cles were categorized on the basis of the way they cited
Schlundt et al (10) as accurate, mildly misleading positive,
explicitly misleading positive, mildly misleading negative,
explicitly misleading negative, neutral, inaccurate unre-
lated, and otherwise unrelated. Positive was defined as
misleadingly citing the results to make breakfast seem
more beneficial, and negative was defined as misleadingly
citing the results to make breakfast seem detrimental. Neu-
tral meant that results were cited as indicating that break-
fast and weight had no relation and did not mention the
interaction trend, and the 2 unrelated categories indicated
that breakfast and weight results were not cited (eg, the
citation was related to other study aspects).
4) Improper use of causal language in citing others’ work.
We examined to what extent authors extrapolated beyond
the limitations of the study design when citing a National
Weight Control Registry (NWCR) study by Wyatt et al
(11). Wyatt et al (11) observed that “A large proportion
of NWCR subjects (2313 or 78%) reported regularly eat-
ing breakfast every day of the week. Only 114 subjects
(4%) reported never eating breakfast. There was no dif-
TABLE 2
Quotations that show breakfast is widely believed to protect against obesity
Quotation
The fact is, when you’re trying to lose body fat, you can’t skip breakfast.
.there’s ample evidence that the simple act of eating breakfast–every day–is a big
part of losing weight, lots of weight.
Eating a healthy breakfast is a good way to start the day and may be important in
achieving and maintaining a healthy weight.
Skipping breakfast to lose weight makes you fatter - and far more likely to raid the
vending machine.
Make sure to eat a healthy breakfast no later than 9 a.m., even if it means placing a
bowl of oatmeal on your dressing table to eat while you put on your makeup.
Studies show that breakfast can be important in maintaining a healthy body weight.
With benefits of decreased body mass index, reduced fatigue, and improved
cognition, we should all eat our Wheaties to start the day!
In fact, skipping breakfast actually increases your risk of obesity.
Research provides evidence that the simple act of eating breakfast every day is a
big part of losing weight.
Want to trim your waist? Try eating breakfast!
ference in reported energy intake between breakfast
eaters and non-eaters, but breakfast eaters reported slightly
more physical activity than non-breakfast eaters (p=0.05).”
(11)
This study was chosen because 1) it was fairly well cited
[we identified a total of 91 articles that cited Wyatt et al
(11) in English as described previously for Schlundt et al
(10), of which 72 articles cited Wyatt et al (11) regarding
the PEBO]; and 2) the NWCR describes a case series,
which meant common behaviors observed within this
population simply co-occurred with weight-loss mainte-
nance, and therefore showed neither an association nor
causation. Citations were rated as stating that the NWCR
article concluded the relation between breakfast and obesity
was causal or associative or correctly stated that the NWCR
simply observed co-occurrence. The rest of the citations
were rated as qualified associative or causal as previously
described.
Downloaded from ajcn.nutrition.org by guest on April 30, 2016
RESULTS
The PEBO is widely stated as true
We identified numerous statements and recommendations
encouraging individuals to eat breakfast with the express purpose
of influencing obesity. These recommendations came from
popular health icons (12) and respected web-based health in-
formation outlets (13) and even the United States Surgeon
General (14) (Table 2). Some statements included uncertainty
(14), whereas other statements were hyperbolic and attributed
unfounded behaviors to skipping breakfast [eg, “raiding the
vending machine” (15)], and still other statements created spe-
cific temporal constraints on when breakfast must be consumed
(16). A satellite symposium at Nutrition Society’s 2012 summer
meeting was even titled “How does breakfast help manage
bodyweight?” (22) Although we cannot conclude that there is
universal agreement in lay-media, government, and scientific-
opinion leaders from these exemplars, we concluded that the
PEBO is widely presumed true, as previously suggested (1).
Source
Dr Oz (12)
WebMD (13)
US Surgeon General 14)
Daily Mail (15)
Discovery Health (16)
Johns Hopkins Bloomberg School of Public Health (17)
NYU Langone Internal Medicine Blog (18)
Mayo Clinic (19)
Scale Back Alabama (20)
Academy of Nutrition and Dietetics (21)
 BREAKFAST, OBESITY, AND BIAS 1301
TABLE 3
Randomized controlled trials that investigated breakfast interventions and obesity
First author, year of
publication (reference) Study length Treatment description Relevant results Notes

Schlundt, 1992 (10)
Geliebter, 2000 (23)
Farshchi, 2005 (24)
12 wk Skipping or eating breakfast
stratified by baseline
breakfast habits
4 wk Oatmeal, corn flakes, or
water for breakfast
2 wk Controlled chronobiological
study in which breakfast
calories were shifted to
Habitual breakfast eaters Interaction effect was
assigned to skip breakfast P , 0.06
and habitual breakfast
skippers assigned to eat
breakfast lost more
weight than subjects who
maintained their
breakfast habits; no main
effect of breakfast on
weight loss.
Water group lost 1.2 kg; Specific breakfast foods
breakfast groups did not
change weight. No
changes in lean and fat
mass in groups.
No significant differences in Controlled calories at
weight, anthropometric subsequent eating
measures, or body occasions

Downloaded from ajcn.nutrition.org by guest on April 30, 2016

Hirsch, 1975 (25)
Crepinsek, 2006 (26)
Powell, 1998 (27)
Ask, 2006 (28)
Rosado, 2008 (29)
lunch composition.
1 wk/arm All food consumed at dinner Dinner-only resulted in Not specifically breakfast
or at breakfast; crossover a relative increase in compared with no
weight compared with breakfast
breakfast-only.
3 school years Universal-free school No difference in BMI or Not specifically breakfast
breakfast compared with percentage of students compared with no
standard School overweight. breakfast
Breakfast Program
1 school year Breakfast or a quarter of an Breakfast intervention One-half of children were
orange resulted in increased less than 21 SD weight-
weight. for-age; not specifically
breakfast compared with
no breakfast
4 mo Free breakfast and Weight increased in control Unclear if control and
supplements compared group and M subjects of intervention groups were
with control intervention; BMI compared; one class
increased in control room per treatment; not
group but not in specifically breakfast
intervention. compared with no
breakfast
12 wk Ready-to-eat-cereal or No significant difference in Included unrelated
habitual intake weight between groups. additional treatment
groups; not specifically
breakfast compared with
no breakfast

Research does not clearly confirm or refute the PEBO
RCTs
There have been very few RCTs that investigated breakfast and
weight change. RCTs related to the PEBO, with no consistent
evidence that breakfast affects weight, are summarized in Table
3. One study even suggests that whether eating or skipping
breakfast is more effective for weight loss depends on the in-
dividual’s typical breakfast habits (10).
the rest of the day. Although some studies showed a decreased
energy intake at a subsequent eating occasion after eating
compared with skipping breakfast, none of the studies showed
a decrease in the sum of calories consumed across the study
period when breakfast was eaten rather than skipped (Table 4).
Other potential mechanisms have been proposed for the PEBO,
such as chronobiology-dependent changes in metabolism;
however, there is currently no clearly and consistently shown
physiologic mechanism to explain the PEBO.

Intermediate endpoint studies Observational evidence

Physiologic and behavioral mechanisms have been proposed Of the 88 abstracts used to investigate BRR, 86% of studies
to link breakfast and obesity, with the primary one being that were cross-sectional. Longitudinal analyses used various
breakfast consumption will result in a decreased cumulative measures of breakfast exposure, despite the relation between
energy intake by causing a compensatory hypophagia throughout breakfast and obesity that potentially depends on how an individual
1302 BROWN ET AL
TABLE 4
Studies that evaluated breakfast and energy intake
First author, year of
publication (reference) Study length Treatment description Relevant results Notes

Astbury, 2011 (30) 1-d crossover Breakfast or no breakfast; No significant differences in Significant increased ad libitum
plus liquid preload total energy intake (breakfast, test meal intake in no-breakfast
before lunch preload, and ad libitum lunch) group
Geliebter, 1999 (31) 1-d crossover 350 kcal oatmeal, sugared Liquid test meal intake was lower Overweight M and F subjects
cornflakes, or water control in the oatmeal but not cornflake
conditions compared with water
control
Geliebter, 1999 (32) 1-d crossover 350 kcal oatmeal, sugared Liquid test meal intake was lower Lean and overweight M and F
cornflakes, or water control in the oatmeal but not cornflake subjects; overweight subjects
conditions compared with water ingested even less after
control consumption of oatmeal
Kral, 2011 (33) 1-d crossover Breakfast or no breakfast Significantly higher energy intake Similar intakes at lunch and rest
in breakfast group of day
Leidy, 2011 (34) 1-d crossover No breakfast, normal breakfast, No significant differences in total Protein-rich breakfast lowered
or high-protein breakfast energy intake lunch intake compared with
that with normal and no breakfast
1) Levitsky, 2013 (35) 1-d crossover High carbohydrate, high fiber, Significantly higher energy intake Similar intakes at lunch
or no breakfast; 1.4-MJ in breakfast groups (breakfast

Downloaded from ajcn.nutrition.org by guest on April 30, 2016

breakfasts plus lunch)
2) Levitsky, 2013 (35) 1-d crossover Ad libitum or no breakfast Significantly higher daily intake in Significant increase in lunch intake
breakfast group for no-breakfast group
Taylor, 2001(36) 2-d crossover 6 meals/d compared with No significant differences in total Wide range of BMI above
4 or 2 meals/d energy expenditure or intake overweight; F only

defines breakfast eating (eg, number of days per week; including
only certain foods) and obesity (eg, categorical obesity, con-
tinuous BMI, including or excluding overweight) (37) and were
generally weak because of dataset limitations. There is a clear
association between breakfast omission and excess weight as
summarized in our cumulative meta-analysis (see RLPV be-
low), and this association supports the PEBO but does not
show causation.
RLPV
Studies included in the cumulative meta-analysis were con-
ducted in 30 countries on 5 continents (Figure 1; countries in
dark gray) with a variety of subpopulations (eg, rural and urban
and men and women) and, thus, provide a widely generalizable
association. Consistent with the general recommendations
shown in Table 2 to eat breakfast with no regard for sub-
populations, all OR estimates were pooled together regardless

FIGURE 1. Map of countries where the proposed effect of breakfast on obesity has been studied. Dark gray denotes studies used in the meta-analysis or
abstract analysis (n = 30). Black denotes studies used in the abstract analysis only (n = 6).
 BREAKFAST, OBESITY, AND BIAS 1303
that, by 1998, after synthesizing only 5 estimates, the P value
was ,0.001, which Sterne and Smith proposed to be interpreted
as strong evidence of a relation (38). By 2011, the P value was
,10242. Although no universal threshold exists for what con-
stitutes sufficient observational evidence, we posit that 10242 is
excessive, and therefore, it was gratuitous to conduct additional
association studies regarding the PEBO well before 2011.

Evidence of BRR in abstracts and citing behaviors

Of our 4 examples of BRR, the first 2 examples represented
infidelity in the reporting of one’s own work, whereas the second
2 examples represented the distortion of others’ research.

Biased interpretation of one’s own results

FIGURE 2. Funnel plot of the meta-analysis. Dots represent each of 88
independent study group OR estimates. The vertical dashed line represents
the meta-analyzed log OR. The solid line is an unweighted transformation of
the Egger’s linear regression test for funnel-plot asymmetry (9). The weighted
intercept (0.5345) shows modest evidence of funnel-plot asymmetry (P =
If all 88 of the rated abstracts accurately reported results and
conclusions, and all of these articles only investigated breakfast and
obesity, all counts should appear on the diagonal in Figure 4, which
was not the case (ie, all diagonal cells should be black). In par-
ticular, 65% of studies that reported positive results for breakfast

Downloaded from ajcn.nutrition.org by guest on April 30, 2016

0.0856), which may represent a publication bias, unaccounted heteroge-
neity in the meta-analysis, or asymmetry by chance.
of the subpopulation. The meta-analysis of the 88 study groups
resulted in a pooled OR of 1.55 (95% CI: 1.46, 1.65) (see
Supplemental Figure S1 under “Supplemental data” in the on-
line issue), with modest evidence of funnel-plot asymmetry as
assessed graphically and by using Egger’s linear regression (P =
0.0856) (9) (Figure 2). Such asymmetry can be indicative of
a publication bias, unaccounted heterogeneity in the analysis, or
asymmetry by chance.
The cumulative association between breakfast and obesity was
significant at a = 0.05 (2-tailed test) after the first year, which
included only 3 study groups, and remained so throughout the
entire cumulative time course (Figure 3). Of particular note was
also mentioned the results in the abstract’s conclusion compared
with only 39% of studies with nonpositive results (2-proportion
test: P = 0.0492). Thus, a disproportionate number of abstracts
with nonpositive results failed to include a nonpositive conclusion.
Note that none of the studies that reported positive results had
conclusions categorized as no relation, negative, or mixed,
whereas one abstract that did not mention breakfast and obesity in
the results still had a positive conclusion toward the PEBO.
Improper use of causal language to describe one’s own results
Language that concluded a finding of cause and effect was not
appropriate for this set of 88 abstracts from observational studies.
However, of the 42 abstracts that included conclusions about
breakfast and obesity, 11 abstracts made unqualified causal
claims about breakfast consumption and obesity, whereas an

FIGURE 3. Cumulative meta-analysis of studies analyzed in the meta-analysis. Each data point represents the synthesis of all studies included year on year
(n = 58 studies with 88 independent groups). Diamonds represent the ORs of skipping breakfast and being overweight or obese bounded by a 95% CI. The
black horizontal line is set at an OR of 1. The final OR is 1.55 (95% CI: 1.46, 1.65). Squares represent P values of ORs for each year of the analysis. Two
horizontal dotted lines represent the traditional P = 0.05 significance and P = 0.001, which was suggested to represent strong evidence of an association (38).
The final P value is 10242.
1304 BROWN ET AL

FIGURE 4. Concordance between results and conclusions from 88 identified abstracts. Abstracts were rated on the basis of whether the results or
conclusions stated that eating breakfast was associated with lower obesity (Positive), showed no relation between breakfast and obesity (No Relation),
showed that eating breakfast was associated with higher obesity (Negative), showed mixed relations (Mixed), or did not mention an analysis between breakfast
and obesity (None). Cell shading represents the percentage of conclusion ratings within a result-rating column, with black representing 100% and white
representing 0%. Marginal counts are not shaded.

additional 10 abstracts used qualifiers to introduce uncertainty
into the causal statements; 21 articles limited the abstract con-
clusions to noncausal language (Figure 5). Thus, 26–50% of
studies were ascribed greater inferential strength than the study
designs warranted.
Misleadingly citing others’ results
citations), and they were almost exclusively biased in favor of
breakfast.
Improper use of causal language in citing others’ work
Of the 91 articles that cited Wyatt et al (11), 72 articles cited the
article with respect to the PEBO. Of these articles, 29% correctly
described the relation between breakfast and weight-loss main-

Downloaded from ajcn.nutrition.org by guest on April 30, 2016

Of the 91 articles that cited Schlundt et al (10) , 46 articles cited
the article with respect to the PEBO, whereas the other citations
were related to other endpoints (eg, snacking frequency) or were
otherwise unrelated (Figure 6). Of the PEBO-relevant citations,
only 17% of articles cited the results accurately. Of the 29 ar-
ticles that misleadingly cited Schlundt et al (10), 28 articles
mildly or explicitly cited Schlundt et al (10) positively toward
breakfast with only 1 article that cited Schlundt et al (10) neg-
atively toward breakfast (P = 1.12 3 10–7; 2-sided binomial test
against H0: P-positive|misleading citation = 0.5). The only ar-
ticle (2%) that cited the results misleadingly negatively toward
breakfast also cited the results accurately elsewhere in the article
(44). These results show that a sizeable number of citations of
Schlundt et al (10) were misleading (62% of the PEBO-relevant
tenance as simply co-occurring, whereas 26% stated the 2 were
associated, and 22% made statements that causally linked
breakfast and obesity (Figure 7). The rest of the articles were
rated qualified associative or causal (4% and 18% of relevant
abstracts, respectively). Thus, 48% of the PEBO-relevant citations
of Wyatt et al (11) explicitly ascribed a stronger inferential
meaning to the article than was warranted, with an additional 22%
of articles that potentially did so depending on the interpretation.
DISCUSSION
We have shown that 1) the PEBO is presumed and stated as
true despite equivocal evidence; 2) the gratuitous replication
of associations between breakfast and obesity showed that

FIGURE 5. Authors’ use of causative language in their own observational studies. The left pie chart shows that 48% (n = 42) of 88 abstracts made
conclusions about breakfast and weight, which is broken down by the use of causal language in the right pie chart.
 BREAKFAST, OBESITY, AND BIAS 1305

Downloaded from ajcn.nutrition.org by guest on April 30, 2016

FIGURE 6. Categorization of 91 articles that cited Schlundt et al (10). Articles that cited Schlundt et al (10) were categorized as shown in the table inset in
the figure. All articles were included in the left pie chart, with only the relevant citations presented in the right pie chart (n = 42). 1The one study that was
explicitly misleadingly negative also cited Schlundt et al (10) accurately elsewhere in the article.

numerous nonprobative studies exist in the PEBO literature; and We reiterate that we used breakfast and obesity as an example
3) there is evidence of a bias with respect to the reporting of for RLPV and BRR and did not consider other important asso-
one’s own and others’ research. ciations with breakfast, such as cognitive function, or other

FIGURE 7. The use of causal language in 91 articles that cited Wyatt et al (11). Articles that cited Wyatt et al (11) were categorized as shown in the table inset
in the figure. The left pie chart represents all articles that cited Wyatt et al (11), whereas the right pie chart was limited to relevant citations (n = 72). 1Unratable
citations include accurate citations unrelated to breakfast and weight and citations for which it was unclear what was being attributed to the Wyatt et al (11) article.
1306 BROWN ET AL

important associations with obesity, such as fruit and vegetable
consumption. We also acknowledge that our analysis may not
have been fully comprehensive because we selected studies on
the basis of previous research syntheses from which we could
calculate ORs. However, additional studies that might have been
identified from a de novo systematic review were unlikely to
meaningfully affect the final P value of the cumulative meta-
analysis because of its magnitude and only weak evidence of
a publication bias. Therefore, additional unidentified studies
would have likely contributed to our conclusion that the asso-
ciation has been excessively established.
Our cumulative meta-analysis that showed the presence of
RLPV had a final P value ,10242, which was almost forty
degrees of magnitude less than the proposed significance level of
Sterne and Smith (38). Despite this gratuitous replication of
effort, we are still uncertain of the role that breakfast plays in
obesity because these observational studies informed association
and not necessarily causation. Each study and analysis that is
conducted costs time and resources that could be dedicated to
unveiling novel associations or engaging in randomized trials
that can better define causal relations. Therefore, the evidence of
sources if a manuscript is being written. Unfortunately, there is an
obligation to make nonprobative replications publicly available,
regardless of the outcome, lest we encourage publication bias.
Perhaps a more useful exercise would be for researchers to better
reflect on the body of evidence before engaging in research. This
exercise could be facilitated by research registration that is
subjected to peer review (56).
Another means of increasing the marginal probative value of
a study relative to an established body of research evidence is to
conduct experiments that directly test the relation of interest
rather than creating causal extrapolations from observational or
intermediate-endpoint studies in obesity (57). These experiments
can often be conducted with established designs, are generally
cost effective, and often have relatively low ethical concern,
particularly when studying nutrition. However, the United States
and WHO clinical trial registries have only 1 study registered to
test the PEBO (as of 9 October 2012; www.clinicaltrials.gov;
NCT01781780). Researchers with the Nutrition Obesity Re-
search Center at the University of Alabama at Birmingham, in
collaboration with other research centers, are conducting an
effectiveness study that will test recommendations to eat

Downloaded from ajcn.nutrition.org by guest on April 30, 2016

RLPV is also evidence of an unproductive use of scientific re-
sources.
We do not suggest that replication be suppressed (55); rather
we want to discourage gratuitous replication. Some journals, eg,
now require bullet points that identify what is already known
compared with what is needed. Although this may help stifle the
publication of RLPV, the research has already consumed re-
breakfast or not to eat breakfast, as well as having a control group,
over 16 wk at 5 sites, with groups stratified by typical breakfast-
consumption habits. Not including personnel costs, the study is
estimated to cost in the neighborhood of $40,000. This study
shows the feasibility of conducting randomized controlled trials
on obesity-targeted population health recommendations rather
than relying on observational extrapolations.

FIGURE 8. Hypothetical model of how BRR and RLPV may be involved in perpetuating presumptions. A: Exposure to such phrases as “breakfast is the
most important meal of the day” may predispose individuals to believe positive things about breakfast because of the “halo effect” (58). B: The RLPV related
to the PEBO may augment this predisposition to believe the PEBO through the “mere exposure effect,” (59) particularly when the research is presented in
a biased manner (eg, in the presence of BRR). C: Individuals tend to seek out information confirming their point of view and reject information to the contrary
(confirmation bias) to prevent or reduce cognitive dissonance (60), thereby retaining a biased sample of information. D. A hypothetical illustrative graph of the
comparison of strength of conviction compared with the strength of existing evidence supporting the PEBO. E: Together, these cognitive biases may
predispose researchers to bias their research reporting, which, thereby, would feed the cycle. BRR, biased research reporting; PEBO, proposed effect of
breakfast on obesity; RLPV, research lacking probative value.
 BREAKFAST, OBESITY, AND BIAS
It is unclear why BRR and RLPV are present in the PEBO
literature. A hypothetical framework to tie these factors together
is shown in Figure 8. Frequent assertions of the general benefits
of consuming breakfast, most easily summarized as “breakfast is
the most important meal of the day,” could potentially pre-
dispose individuals to ascribe other positive attributes to
breakfast because of the “halo-effect,” in which some foods are
considered to be intrinsically good and wholesome (58). In
addition, the repeated exposure to RLPV may further predispose
researchers to specifically believe in the PEBO because of the
“mere exposure effect”: individuals tend to believe something to
which they have been repeatedly exposed (59). This pre-
disposition may be exacerbated if the exposure consists of bi-
ased information that communicates stronger conclusions than
the evidence warrants, as shown in BRR. In turn, individuals
may be less likely to seek out or accept information contrary to
their preconceptions (confirmation bias) as a way to decrease the
mental discomfort associated with conflicting information
(cognitive dissonance) (60). A resultant biased mental repository
of information would be consistent with why individuals believe
more strongly in a presumption than the existing evidence ob-
jectively supports (a hypothetical representation is shown in
Figure 8D). Conversely, “white hat bias” (2) suggests the in-
fluence of bias on research distortion may be more direct
whereby individuals (consciously or unconsciously) might ig-
nore the weakness of the scientific evidence regarding a pre-
sumption in favor of believing in the wholesome nature of the
exposure (ie, breakfast) in hopes of addressing a formidable
consequence (ie, obesity). Although we could not directly test
either framework in the current study, we hypothesize that these
factors may influence the propensity of authors to bias research
reporting.
Beyond the investigator-centric framework proposed in Figure
8, the implications of BRR extend to other evidence consumers.
When research reporting is biased, the integrity of scientific
information deteriorates because it drifts from the original
source, much like the childhood game of “telephone.” If the
fidelity of the scientific message cannot be replicated from the
results to conclusions within a study [(as shown in the first and
second examples of BRR in the current article and “spin” by
Boutron et al (61)], the reporting of the scientific finding is
distorted before it even reaches press releases (62). Therefore,
evidence consumers are receiving biased information.
Ironically, raising awareness of a bias often helps individuals
identify biases in others rather than oneself, which is a so-called
“bias blind spot” (63). Although we hope that the results pre-
sented in the current article will help individuals identify biased
reporting in their own work (ourselves included), it is the peer-
review process that may be best improved by raising awareness
of bias. As writers and reviewers, we need to be vigilant for
lapses in objectivity and for studies of nonprobative value to
hopefully keep scientific beliefs grounded in scientific evidence.
The authors’ responsibilities were as follows—AWB and MMBB: con-
ducted the research; AWB: analyzed data; DBA: had primary responsibility
for the final content of the manuscript; and all authors: designed the research,
wrote the article, and approved the final manuscript. AWB has received
consulting fees from Farmland Foods and lecture fees from Danisco. DBA
has served as an unpaid board member for the International Life Sciences
Institute of North America and has received payment for board membership
from Kraft Foods and consulting fees, grants, and/or unrestricted gifts to his
1307
university from Kraft Foods, Kellogg Company, PepsiCo, Jason Pharmaceu-
ticals, and McNeil Nutritionals. MMBB had no conflict of interest.
REFERENCES
1. Casazza K, Fontaine KR, Astrup A, Birch LL, Brown AW, Bohan
Brown MM, Durant N, Dutton G, Foster EM, Heymsfield SB, et al.
Myths, presumptions, and facts about obesity. N Engl J Med 2013;368:
446–54.
2. Cope MB, Allison DB. White hat bias: examples of its presence in
obesity research and a call for renewed commitment to faithfulness in
research reporting. Int J Obes (Lond) 2010;34:84–8.
3. Weed DL, Althuis MD, Mink PJ. Quality of reviews on sugar-sweetened
beverages and health outcomes: a systematic review. Am J Clin Nutr
2011;94:1340–7.
4. Cope MB, Allison DB. Critical review of the World Health Organi-
zation’s (WHO) 2007 report on ’evidence of the long-term effects of
breastfeeding: systematic reviews and meta-analysis’ with respect to
obesity. Obes Rev 2008;9:594–605.
5. Horikawa C, Kodama S, Yachi Y, Heianza Y, Hirasawa R, Ibe Y, Saito
K, Shimano H, Yamada N, Sone H. Skipping breakfast and prevalence
of overweight and obesity in Asian and Pacific regions: a meta-anal-
ysis. Prev Med 2011;53:260–7.
6. Mesas AE, Munoz-Pareja M, Lopez-Garcia E, Rodriguez-Artalejo F.
Downloaded from ajcn.nutrition.org by guest on April 30, 2016
Selected eating behaviours and excess body weight: a systematic re-
view. Obes Rev 2012;13:106–35.
7. Rampersaud GC, Pereira MA, Girard BL, Adams J, Metzl JD.
Breakfast habits, nutritional status, body weight, and academic per-
formance in children and adolescents. J Am Diet Assoc 2005;105:743–
60; quiz 61–2.
8. Szajewska H, Ruszczynski M. Systematic review demonstrating that
breakfast consumption influences body weight outcomes in children
and adolescents in Europe. Crit Rev Food Sci Nutr 2010;50:113–9.
9. Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-
analysis detected by a simple, graphical test. BMJ 1997;315:629–34.
10. Schlundt DG, Hill JO, Sbrocco T, Pope-Cordle J, Sharp T. The role of
breakfast in the treatment of obesity: a randomized clinical trial. Am J
Clin Nutr 1992;55:645–51.
11. Wyatt HR, Grunwald GK, Mosca CL, Klem ML, Wing RR, Hill JO.
Long-term weight loss and breakfast in subjects in the National Weight
Control Registry. Obes Res 2002;10:78–82.
12. Lynn L. Breakfast shakes: drink yourself skinny. 26 October 2011.
Available from: http://www.doctoroz.com/blog/lisa-lynn/breakfast-
shakes-drink-yourself-skinny (cited 17 January 2013).
13. Davis JL. Lose weight: eat breakfast. 31 August 2010. Available from:
http://www.webmd.com/diet/features/lose-weight-eat-breakfast (cited
20 November 2012).
14. SurgeonGeneral.gov. The Surgeon General’s call to action to prevent
and decrease overweight and obesity: overweight in children and
adolescents. Available from: http://www.surgeongeneral.gov/library/
calls/obesity/fact_adolescents.html (cited 20 November 2012).
15. Macrae F. Skipping breakfast to lose weight makes you fatter - and far
more likely to raid the vending machine. 16 October 2012. Available
from: http://www.dailymail.co.uk/health/article-2218649/Skipping-
breakfast-cause-weight-GAIN-weight-loss.html (cited 20 November
2012).
16. Peeke P. Dr. Pamela Peeke’s 10 weight-prevention tips. Available from:
http://health.howstuffworks.com/wellness/diet-fitness/weight-loss/10-
toxic-weight-prevention-tips1.htm (cited 20 November 2012).
17. Health JHBSoP. Breakfast. Available from: http://www.jhsph.edu/
offices-and-services/student-affairs/Breakfast (cited 17 January 2013).
18. Che C. Myths and realities: is breakfast the most important meal of the
day? 18 June 2009. Available from: http://www.clinicalcorrelations.
org/?p=1525 (cited 20 November 2012).
19. Zeratsky K. Why does eating a healthy breakfast help control weight?
23 July 2011. Available from: http://www.mayoclinic.com/health/food-
and-nutrition/AN01119/ (cited 20 November 2012).
20. Alabama SB. Choosing breakfast as a lifestyle habit. 2011. Available
from: http://www.scalebackalabama.com/toolkit/2011/lessonplans/
Lesson6_ChoosingBreakfast.pdf (cited 20 November 2012).
21. Blake JS. Want to trim your waist? Try eating breakfast! 15 Novemeber
2010. Available from: http://www.eatright.org/Media/Blog.aspx?id=
4294969065&blogid=269 (cited 20 November 2012).
1308 BROWN ET AL
22. Ashwell M, De la Hunty A. How does breakfast help manage body-
weight? Nutr Bull 2012;37:395–7.
23. Geliebter A, Yahav E, Haq S, Hashim SA. Cholesterol and weight
change following daily high or low fiber breakfast cereals. Obes Res
2000;8:25S.
24. Farshchi HR, Taylor MA, Macdonald IA. Deleterious effects of
omitting breakfast on insulin sensitivity and fasting lipid profiles in
healthy lean women. Am J Clin Nutr 2005;81:388–96.
25. Hirsch EHE, Halberg F, Goetz FC, Cressey D, Wendt H, Sothern R,
Haus E, Stoney P, Minors D, Rosen G, et al. Body weight change
during 1 week on a single daily 2000-calorie meal consumed as
breakfast (B) or dinner (D). Chronobiologia 1975;2(suppl 1):31–2.
26. Crepinsek MK, Singh A, Bernstein LS, McLaughlin JE. Dietary effects
of universal-free school breakfast: findings from the evaluation of the
school breakfast program pilot project. J Am Diet Assoc 2006;106:
1796–803.
27. Powell CA, Walker SP, Chang SM, Grantham-McGregor SM. Nutrition
and education: a randomized trial of the effects of breakfast in rural
primary school children. Am J Clin Nutr 1998;68:873–9.
28. Ask AS, Hernes S, Aarek I, Johannessen G, Haugen M. Changes in
dietary pattern in 15 year old adolescents following a 4 month dietary
intervention with school breakfast–a pilot study. Nutr J 2006;5:33.
29. Rosado JL, del R Arellano M, Montemayor K, Garcı́a OP, Caamaño
Mdel C. An increase of cereal intake as an approach to weight re-
duction in children is effective only when accompanied by nutrition
education: a randomized controlled trial. Nutr J 2008;7:28.
30. Astbury NM, Taylor MA, Macdonald IA. Breakfast consumption af-
fects appetite, energy intake, and the metabolic and endocrine re-
sponses to foods consumed later in the day in male habitual breakfast
eaters. J Nutr 2011;141:1381–9.
31. Geliebter A, Yahav E, Forbes G, Hashim SA. Lunch meal intake fol-
lowing high and low glycemic breakfast cereals. FASEB J 1999;13:
A871–A.
32. Geliebter A, Yahav E, Biase B, Hashim SA. Lunch meal intake fol-
lowing high and low fiber breakfast cereals. Obes Res 1999;7:44S.
33. Kral TV, Whiteford LM, Heo M, Faith MS. Effects of eating breakfast
compared with skipping breakfast on ratings of appetite and intake at
subsequent meals in 8- to 10-y-old children. Am J Clin Nutr 2011;93:
284–91.
34. Leidy HJ, Racki EM. The addition of a protein-rich breakfast and its
effects on acute appetite control and food intake in ’breakfast-skipping’
adolescents. Int J Obes 2010;34:1125–33.
35. Levitsky DA, Pacanowski CR. Effect of skipping breakfast on sub-
sequent energy intake. Physiol Behav 2013;119:9–16.
36. Taylor MA, Garrow JS. Compared with nibbling, neither gorging nor
a morning fast affect short-term energy balance in obese patients in
a chamber calorimeter. Int J Obes Relat Metab Disord 2001;25:519–28.
37. Dialektakou KD, Vranas PB. Breakfast skipping and body mass index
among adolescents in Greece: whether an association exists depends on
how breakfast skipping is defined. J Am Diet Assoc 2008;108:1517–25.
38. Sterne JA, Davey Smith G. Sifting the evidence-what’s wrong with
significance tests? BMJ 2001;322:226–31.
39. Croezen S, Visscher TL, Ter Bogt NC, Veling ML, Haveman-Nies A.
Skipping breakfast, alcohol consumption and physical inactivity as
risk factors for overweight and obesity in adolescents: results of the
E-MOVO project. Eur J Clin Nutr 2009;63:405–12.
40. Kent LM, Worsley A. Breakfast size is related to body mass index for
men, but not women. Nutr Res 2010;30:240–5.
41. Fabritius K, Rasmussen M. [Breakfast habits and overweight in Danish
schoolchildren. The role of socioeconomic positions] Ugeskr Laeger
2008;170:2559–63 (in Danish).
42. Song WO, Chun OK, Obayashi S, Cho S, Chung CE. Is consumption of
breakfast associated with body mass index in US adults? J Am Diet
Assoc 2005;105:1373–82.
43. Booth CK, Reilly C, Farmakalidis E. Mineral composition of Austra-
lian ready-to-eat breakfast cereals. J Food Compost Anal 1996;9:135–47.
44. Berkey CS, Rockett HR, Gillman MW, Field AE, Colditz GA. Lon-
gitudinal study of skipping breakfast and weight change in adolescents.
Int J Obes Relat Metab Disord 2003;27:1258–66.
45. Masheb RM, Grilo CM, White MA. An examination of eating patterns
in community women with bulimia nervosa and binge eating disorder.
Int J Eat Disord 2011;44:618–24.
46. Ozdogan AGY, Ozcelik AO, Surucuoglu MS. The breakfast habits of
female university students. Pakistan J Nutr 2010;9:882–6.
47. Turnin MC, Bourgeois O, Cathelineau G, Leguerrier AM, Halimi S,
Sandre-Banon D, Coliche V, Breux M, Verlet E, Labrousse F, et al.
Multicenter randomized evaluation of a nutritional education software
in obese patients. Diabetes Metab 2001;27:139–47.
48. Fiore H, Travis S, Whalen A, Auinger P, Ryan S. Potentially protective
factors associated with healthful body mass index in adolescents with
obese and nonobese parents: a secondary data analysis of the Third
National Health And Nutrition Examination Survey, 1988-1994. J Am
Diet Assoc 2006;106:55–64; quiz 76–9.
49. Carels RA, Young KM, Coit C, Clayton AM, Spencer A, Wagner M.
Skipping meals and alcohol consumption. The regulation of energy
intake and expenditure among weight loss participants. Appetite 2008;
51:538–45.
50. Albertson AM, Anderson GH, Crockett SJ, Goebel MT. Ready-to-eat
cereal consumption: its relationship with BMI and nutrient intake of
children aged 4 to 12 years. J Am Diet Assoc 2003;103:1613–9.
Downloaded from ajcn.nutrition.org by guest on April 30, 2016
51. di Giuseppe R, Di Castelnuovo A, Melegari C, De Lucia F, Santimone
I, Sciarretta A, Barisciano P, Persichillo M, De Curtis A, Zito F, et al.
Typical breakfast food consumption and risk factors for cardiovascular
disease in a large sample of Italian adults. Nutrition, metabolism, and
cardiovascular diseases. Nutr Metab Cardiovasc Dis 2012;22:347–54.
52. Schaffner M. Always. Gastroenterol Nurs 2007;30:437–8.
53. Raynor HA, Jeffery RW, Ruggiero AM, Clark JM, Delahanty LM,
Look ARG. Weight loss strategies associated with BMI in overweight
adults with type 2 diabetes at entry into the Look AHEAD (Action for
Health in Diabetes) trial. Diabetes Care 2008;31:1299–304.
54. Cho S, Dietrich M, Brown CJ, Clark CA, Block G. The effect of
breakfast type on total daily energy intake and body mass index: results
from the Third National Health and Nutrition Examination Survey
(NHANES III). J Am Coll Nutr 2003;22:296–302.
55. Laws KR. Negativland - a home for all findings in psychology. BMC
Psychology 2013;1.
56. Neuroskeptic. Fixing science - systems and politics. 14 April 2012.
Available from: http://neuroskeptic.blogspot.co.uk/2012/04/fixing-science-
systems-and-politics.html (cited 03 April 2013).
57. Casazza K, Allison D. Stagnation in the clinical, community and public
health domain of obesity: the need for probative research. Clin Obes
2012;2:83–5.
58. Chandon P, Wansink B. The biasing health halos of fast-food restaurant
health claims: lower calorie estimates and higher side-dish consump-
tion intentions. J Consum Res 2007;34:301–14.
59. Kahneman D. Thinking fast and slow. New York, NY: Farrar, Straus
and Giroux, 2011.
60. Festinger L. A theory of cognitive dissonance. Stanford, CA: Standford
University Press, 1957.
61. Boutron I, Dutton S, Ravaud P, Altman DG. Reporting and inter-
pretation of randomized controlled trials with statistically nonsig-
nificant results for primary outcomes. JAMA 2010;303:2058–64.
62. Yavchitz A, Boutron I, Bafeta A, Marroun I, Charles P, Mantz J,
Ravaud P. Misrepresentation of randomized controlled trials in press
releases and news coverage: a cohort study. PLoS Med 2012;9:
e1001308.
63. Pronin E, Lin DY, Ross L. The bias blind spot: perceptions of bias in
self versus others. Pers Soc Psychol Bull 2002;28:369–81.