The Magnitude of Malnutrition
In fact, micronutrient deficiencies are widely prevalent in African countries. Twenty six percent of the children suffering from vitamin A deficiency (VAD) live in Africa, with the largest proportion in sub-Saharan Africa(6). According to the Kenya Ministry of Health(7), the prevalence of severe VAD is 14% and moderate VAD is 61% among children under 5. Other major micronutrient deficiencies in Africa include iodine deficiency disorder, iron deficiency anaemia and zinc deficiency, with high rates among young children. Approximately 25% of children are iodine deficient(8). Studies in Kenya show that 56% school age children are anaemic and especially girls. In some regions this is as high as 89.5% due to food insecurity and poverty(9,10,11). Half of the children under five years are zinc deficient(12,13,8).
Micronutrient deficiencies may have adverse effects on children’s growth and development. However, also inadequate intake of energy and protein will impair physical growth, leading to thinness and stunting. The global prevalence of stunting - when a child is too short for his age - has decreased over the past decades, however, still 161 million children under the age of five years are stunted(14). The vast majority is living in Sub-Saharan Africa and South Asia, where 38% of the children under five years old are stunted(15). According to the Kenya Demographic and Health Survey(16) 25% of the children under five are stunted in Kenya. Underweight - when a child’s weight is too small for their age - is at a national average of 11%.
Next to undernutrition, the prevalence of overweight is also increasing in developing countries(17), including Kenya. However, this problem has not been addressed adequately by nutrition surveys in Kenya. Overweight in Children has not significantly change from 6% in 1993, 2003 (6%), 2008-09 (5%) and 2014 (4%)(16). The study indicates that in adult women there is an increasing trend of overweight and obese women at 25% in 2008-09 and 33% in 2014. These trends have been associated with a rise in non-communicable diseases such as diabetes, hypertension, heart disease and cancer(16).
Good nutrition, an adequate well-balanced diet combined with regular physical activity, is the foundation of good health. Malnutrition can impair our daily health and wellbeing and reduce our ability to lead an enjoyable and active life. Moreover, both under and over nutrition may substantially impact long term health status and life expectancy.
How Can Breakfast Help in Providing Good Nutrition?
Breakfast means ‘break the fast’, as the previous meal is typically 8–10 hours before waking up in the morning. Breakfast is important in re-fuelling the body with energy and nutrients, kick-starting the day. Many dietary guidelines recommend to consume a nutrient dense breakfast daily(18,19). In addition, it is generally recommended by several dietary guidelines that 15 to 25 percent of the recommended daily requirement for nutrient (vitamins and minerals) and energy should come from breakfast.
The consumption of breakfast is associated with healthier daily nutrient intake in all age groups, especially in children and adolescents as an individual is more likely to consume the recommended daily nutrients unlike when breakfast is skipped(20,21,22). For example, a study reported that children who skipped breakfast did not meet two thirds of the recommended daily allowances (RDA; 40-60%) compared with those who consumed breakfast at school (<5-30%) or at home (<5-58%). Cross-sectional data has shown that children and adolescents who consume breakfast, such as, enriched grains and bread, eggs, milk etc. have better macro and micro-nutrient intakes, that is, they are more likely to meet the recommended intake(23,24). Several studies have reported that breakfast consumers had higher intakes of vitamins A, E, C, B-6, and B-12; folate; iron; calcium; phosphorus; magnesium; potassium; and dietary fibre(25,20,26). Cross-sectional data in children shows that the lower micronutrient intake due to breakfast skipping may not be compensated by other meals during the day(20,27). Several observational studies in children and adolescents have suggested that consuming unhealthy snacks instead of breakfast or consuming an unhealthy breakfast may be a contributing factor to unhealthy nutrient profile such as higher intakes of saturated fats, trans fats and sugars(20,26,28).
A Nutritious Breakfast for Healthy Growth and Development of Children
Daily nutritious breakfast consumption may contribute to longer-term healthy growth and development of children. Consequently this may have a positive impact on overall school performance of children in the long term.
Few studies from developing countries have looked into the role of breakfast and physical growth of children. Three studies, one intervention study from Jamaica (29) and two observational studies from China (30,31) reported that breakfast consumption is positively associated with linear growth of children. These studies suggest a positive relation between breakfast and growth but the data is too limited to draw a firm conclusion. However, it can be assumed that the intake of nutritious breakfast (vs. skipping) can help to increase energy intake and nutrient intake. This increase in energy and nutrient intake may positively influence growth especially in undernourished children.
A Nutritious Breakfast Helps Children to Do Better at School: Cognition & School Performance
Children may be vulnerable to the nutritional effects of breakfast on brain activity and associated cognitive outcomes as they have a higher brain glucose metabolism compared with adults (32). The higher metabolic turnover of children, their rapid growth rates and the importance of their cognitive function for academic achievement underlie the need for optimal nutrition including breakfast intake. Most studies on breakfast consumption suggest breakfast to be positively associated with learning in children in terms of behavior, cognitive, and school performance(1). It is generally assumed that the beneficial effects of eating breakfast on cognitive performance are expected to be short term and specific to the morning on which breakfast is eaten and to selective cognitive functions. However, several studies have shown the benefit of habitual or regular breakfast (increased frequency >5 days/week) consumption on academic performance(2,3). At the same time, some evidence suggests that breakfast quality (and not just frequency), in terms of providing a greater variety of food groups (3-4) and adequate energy (>20-25%E of the estimated energy needs), was positively related to school performance(33).
A study by Cardiff University found a significant link between eating breakfast and performing above average on teacher assessment scores. The children who ate a healthy morning meal such as cereal, bread, dairy or fruit were up to twice as likely to achieve better than average grades compared to those who had none and compared to those who snacked on junk foods(34).
What Makes a Good Breakfast?
Breakfast is an important meal of the day. It is generally recommended by several dietary guidelines that 15 to 25 % of recommended daily requirement for nutrients (vitamins and minerals) and energy should come from breakfast. In addition, the amount and type of fats as well as sugar and sodium should be in line with recommendations from the World Health Organization(35). Food based dietary guidelines are developed to help people choose an adequate diet. These guidelines are based on existing consumption of locally available foods and aims to address nutrition-related public health problems. Like for total diets, it is recommended to combine a variety of foods from the different food groups of the food-based dietary guidelines into breakfast.
Breakfast should be commonly based on starchy foods (for example brown bread or whole grain porridge), which should be combined with a hot beverage such as tea with milk, or a portion of milk or other source of protein. Furthermore, it is important to also add a variety of fruits or some vegetables, because these are rich sources of different vitamins and minerals including vitamin C and A, folic acid, potassium, and fibre. In addition, to help get more good fats, it is recommended to add some spread with Omega 3 and 6 fats and fatsoluble vitamins such as margarine.
Therefore, a good breakfast will deliver required nutrients to start the day such as carbohydrates, good fats (Omega 3 and 6), proteins, water soluble and fat-soluble vitamins, and minerals. The food choices for breakfast will depend on what is locally available and accessible. Examples of a good breakfast for Kenyan children could contain local staple foods like sweet potatoes, boiled cassava, boiled arrow root, whole grain chapatti, legumes and nuts, whole grain porridge with some margarine, a fried or boiled egg, whole meal bread spread with margarine, milk (cow, camel, goat, soya) yoghurt, a cup of tea with milk and seasonal fruits.
Good Fats are an Essential Part of a Nutritious Breakfast
It is generally recommended to eat some fat or oil with breakfast, and this fat should be of the right quality. WHO recommends that 6-11% of the daily energy intake should be delivered by polyunsaturated fats (PUFA), which helps prevent chronic diseases. PUFA are mainly the essential fats linoleic acid (LA – omega 6) and alphalinolenic acid (ALA – omega 3), for. Five to eight percent has to come from LA, and 1-2% from ALA(36).
Essential fats cannot be produced by the human body, hence they need to be part of the diet and are needed for vital functions. They are used by the body to synthesise bioactive metabolites (eicosanoids, prostaglandins) via conversion to very long chain fatty acids, and are building blocks for cells and tissues. In children, essential fats are needed for optimal growth and development(37). In addition, polyunsaturated fats can have a beneficial effect on the heart when eaten in moderation and when use to replace saturated fat and trans fat(37). Polyunsaturated fats can help reduce bad (LDL) cholesterol levels the blood which can lower the risk o heart disease and strokes(38,39).
Children across the globe do not get enough of the essential fats; mainly Omega 3 intake is very low(40). A recent study in Indonesia showed that 40% of the children had saturated fat intake exceeding recommendations, while 84% of the children had ALA intakes below recommendations(42). There are no intake data available for children in Kenya.
Vegetable oils that are rich in polyunsaturated fats provide essential fats. Margarine is made with vegetable oils and so provides omega 3 and 6. In addition, it delivers the fat-soluble vitamins A, D and E. Adding margarine to breakfast will provide energy and vitamins, will add taste, and will help children to get the essential fats they need.
Improving Breakfast Behaviour
The Blue Band social program aims to improve the health and well-being and education of children in Kenya by promoting a nutritious breakfast every day.
Starting the day with a nutritious breakfast will help children to get the nutrients they need, and therefore we need to make breakfast a habit for all.
The role of advocacy, social mobilisation and communication cannot be underestimated. Evidence has shown clearly that advocacy and empowerment of individuals, communities and all other relevant stakeholders can bring tangible and sustainable changes in the improvement of the country nutrition profile. Mass media campaigns through television, radio and print media have stepped up efforts to bring positive behavior change in the society. Moreover, appropriate communications through health c facilities and community outreach services have also been used to foster better community nutrition outcomes. The food industry can contribute b developing affordable and accessible nutrient dense products. Blue Ban margarine, for example is a product which provides the essential Omega 6 fats, and a variety of water and fat soluble vitamins. These products can to make a nutritious breakfast available and attractive for every child.
ConclusionThere is need to change breakfast intake behaviour of children as this will help them in their growth and development, acting as a strategy for improved nutrition and health. Achieving behaviour change on good breakfast consumption is a huge task and requires concerted efforts by all nutrition stakeholders. A call to action for every stakeholder would mean active participation in a movement that advocates relentlessly for good breakfast behaviours, which are implemented at household level and reinforced in the school system. In order to ensure that all children in Kenya have a good breakfast at home every day, a Good Breakfast Alliance would be ideal to bring together various nutrition stakeholders from different sectors such as agriculture, health, education, UN agencies, development partners and Non Governmental organizations. This alliance will join efforts to promote behaviour change for good breakfast. The behaviour change will increase the number of children who take breakfast at home every day.