Indian J Pediatr
DOI 10.1007/s12098-016-2049-7
ORIGINAL ARTICLE
Association of Breakfast Intake with Psychiatric Distress
and Violent Behaviors in Iranian Children and Adolescents:
The CASPIAN- IV Study
Zeinab Ahadi 1 & Roya Kelishadi 2 & Mostafa Qorbani 3 & Hoda Zahedi 4 & Mahtab Aram 5 &
Mohammad Esmaeil Motlagh 6 & Gelayol Ardalan 2 & Gita Shafiee 7 &
Seyed Masoud Arzaghi 8 & Hamid Asayesh 9 & Ramin Heshmat 1
Received: 19 September 2015 / Accepted: 25 January 2016
# Dr. K C Chaudhuri Foundation 2016
Abstract
Objective To assess the relationship of breakfast intake with
psychiatric distress and violent behaviors among Iranian chil-
dren and adolescents.
Methods This national survey was conducted among 14,880
students, aged 6–18 y. They were selected by stratified multistage
sampling method from urban and rural areas of 30 provinces of
Iran. Breakfast intake, psychiatric distress, and violent behaviors
were assessed by a questionnaire prepared based on the Global
school-based student health survey of the World Health
Organization. The data were analyzed by the STATA package.
Results The participation rate was 90.6 %. The percentage of
psychiatric distress among breakfast skippers, semi-skippers
and non-skippers was 13.4–50.4, 10.1–41.9, and 7.0–33.3 %
respectively. The prevalence of psychiatric distress was sig-
nificantly higher among breakfast skippers than semi-skippers
* Ramin Heshmat
rheshmat@tums.ac.ir
1
Chronic Diseases Research Center, Endocrinology and Metabolism
Population Sciences Institute, Tehran University of Medical
Sciences, # 111, 19th St, North Kargar Ave., Tehran, Iran
2
Department of Pediatrics, Child Growth and Development Research
Center, Research Institute for Primordial Prevention of
Non-communicable Disease, Isfahan University of Medical
Sciences, Isfahan, Iran
3
Department of Community Medicine, Alborz University of Medical
Sciences, Karaj, Iran
4
Obesity and Eating Habits Research Center, Endocrinology and
Metabolism Molecular -Cellular Sciences Institute, Tehran
University of Medical Sciences, Tehran, Iran
and non-skippers (P value < 0.001). The frequency of psychi-
atric distress had a significant decreasing trend from breakfast
skippers to non-skippers. The prevalence of violent behaviors
was significantly higher among breakfast skippers than non-
skippers. Students who skipped breakfast reported to be more
victimized (29.2 % vs. 26.7 %, respectively, P = 0.04), bullied
(21.0 % vs. 16.2 %, respectively, P < 0.001), and had more
physical fight (42.6 % vs. 38.5 %, respectively, P = 0.0001)
than their other counterparts.
Conclusions Students who regularly consumed breakfast
were less likely to experience mental health disorders and
violent behavior. Adhering to a regular and balanced diet,
besides the awareness of parents on the importance of break-
fast eating, may be an appropriate approach for preventing
mental health problems and violent behavior in children and
adolescents.
5
Department of Clinical Psychology, Science and Research Branch,
Islamic Azad University, Tehran, Iran
6
Department of Pediatrics, Ahvaz University of Medical Sciences,
Ahvaz, Iran
7
Endocrinology and Metabolism Research Center, Endocrinology and
Metabolism Clinical Sciences Institute, Tehran University of Medical
Sciences, Tehran, Iran
8
Elderly Health Research Center, Endocrinology and Metabolism
Population Sciences Institute, Tehran University of Medical
Sciences, Tehran, Iran
9
Department of Medical Emergencies, Qom University of Medical
Sciences, Qom, Iran

Keywords Breakfast . Psychiatric . Bullying . Violence .
Children and adolescents
Introduction
Mental health is a main concern in children and adolescents; it is
predicted that by 2020, mental health disorders will be one of the
strongest global health problems [1]. Global statistics report that
over 22 % of adolescents suffer from mental disorders [2].
Epidemiological data estimates that one in five children is likely
to develop some mental disorder by the time they reach the
adulthood [3]. Mental disorders are associated with health-risk
behaviors including inactivity, smoking, drinking, as well as poor
diet, obesity, and hypertension [4].
Bullying and victimization are common experience and prob-
lematic manners among adolescents. The prevalence of school
bullying is reported between 9 and 54 % [5]. Bullying is associ-
ated with social aggression, being alone, and poor school perfor-
mance [6, 7]; and being a victim of bullying is associated with
mental health disorders included depression, anxiety, attention
deficit disorder, fear, and hyperactivity [8, 9].
It is well documented that eating patterns are associated with
behavior disorders [10, 11], for instance, a healthy diet has been
associated with better mood and better cognitive function.
Breakfast intake is often considered one of important health-
related behaviors. On the other hand, breakfast skipping has
become increasingly prevalent among adolescents [12].
Breakfast skipping is associated with a variety of health-risk
behaviors, such as smoking, repeated alcohol consumption,
and irregular exercise [13], as well as development of over-
weight and obesity [14]. Moreover, breakfast consumption leads
to improvement in school attendance [15], feelings of calmness,
improved mood, and better memory [16]. Previous studies have
shown the association between bullying and eating disorders
[17], but the limited experience exists on the association be-
tween breakfast skipping and violent behaviors.
The aim of this study was to assess the relationship of
breakfast intake with psychiatric distress and violent behav-
iors among Iranian children and adolescents.
Material and Methods
This study was representative of the Iranian students’ popula-
tion aged between 6 and 18 y. The data were gathered in
2011–2012 as part of the fourth survey of a surveillance pro-
gram entitled Childhood and Adolescence Surveillance and
PreventIon of Adult Non-communicable Disease
(CASPIAN-IV) study. The study population was 14,880
Iranian school students, aged 6–18 y. The adolescents were
selected by multistage, cluster sampling methods (48 clusters
of 10 students in each province) from elementary, intermediate
Indian J Pediatr
and high schools of rural and urban areas of the central
counties of 30 provinces of Iran. A detailed description of
the protocol has been published previously [18].
The study was performed according to the declaration of
Helsinki [19] and approved by the institutional review boards
at national and sub-national level. A written informed consent
and verbal consent was obtained from the parents and students;
respectively, after complete description of the procedure in-
volved. The questionnaire was prepared in Persian and was
based on global school-based student health survey (GSHS).
The validity and reliability of questionnaire was confirmed pre-
viously [20].
Breakfast intake, psychiatric distress, and violent behaviors
were assessed by following questions. The psychiatric distress
included worthless, angriness, anxiety, insomnia, confusion, de-
pression and worried problems which were assessed by follow-
ing questions:
Worthless: During the past 6 mo, how often did you have
this problem? (Response options were from 1= approxi-
mately every day to 5= rarely or never)
Angriness: During the past 6 mo, how often did you have
this problem? (Response options were from 1= approxi-
mately every day to 5= rarely or never)
Anxiety: During the past 6 mo, how often did you have
this problem? (Response options were from 1= approxi-
mately every day to 5= rarely or never)
Insomnia: During the past 6 mo, how often did you have
this problem? (Response options were from 1= approxi-
mately every day to 5= rarely or never)
Confusion: During the past 6 mo, how often did you have
this problem? (Response options were from 1= approxi-
mately every day to 5= rarely or never)
Depression: During the past 12 mo, did you ever feel so
sad or hopeless almost every day for 2 wk or more in a
row that you stopped doing your usual activities?
(Response option 1 = yes and 2 = no)
Worried: During the past 12 mo, how often have you been
so worried about something that you could not sleep at
night? (Response options were from 1= never to 5 = always)
Violent behavior questions included bullying, being victim
and physical fight variables.
Bullying: During the past 3 mo, how often did you bully
at school? (Response options were from 1 = I did not
bully to any student at the school to 4 = 4 or more times)
Being victim: During the past 3 mo, how often did you
get bullied at school? (Response options were from 1 =
never to 4 = More than three times)
Physical fight: During the past 12 mo, how many times
were you in a physical fight? (Response option 1 = 0
times to 5 = 4 times)
Indian J Pediatr
Breakfast intake was measured by a single item, “Usually
on how many days of the week do you eat breakfast? On
weekdays and weekends”. Responses raged from “I don’t
eat at all” to “6 d”. Breakfast frequency was defined as skip-
pers (eating breakfast 0–2 d/wk), semi-skippers (eating break-
fast 3–4 d/wk) and non-skippers (eating breakfast 5–7 d/wk).
Socioeconomic status (SES) included father’s job and edu-
cation, mother’s job and education, owning private car and
computer, type of student’s school (private, public) and owner-
ship of house (private, leased and organizational house) vari-
ables. SES was categorized into tertiles. The first tertile was
defined as a low SES, second tertile as an intermediate and third
tertile as a high.
Physical activity was assessed by two questions. 1) During
the past week, on how many days were you physically active
for overall 30 min per day? Response options were from 0 to
7 d. 2) How much time do you spend in exercise class regu-
larly in school per week? Responses ranged from 0 to 3 or
more hours. Physical activity was categorized into tertiles.
The first tertile was defined as mild, second tertile as moderate
and third tertile as severe.
The screen time was assessed by asking the average
time (hours per day) on weekdays and weekends that
participants spent watching, leisure time computer use,
or electronic games. For the analysis, according to the
international recommendations, the screen time was cate-
gorized into two groups of less than 2 h per day (low),
and 2 h per day or more (high) [21].
The data were analyzed by the STATA version 11.0
(STATA Corp, College Station, Tex.). The qualitative var-
iables were reported as percentages and 95 % confidence
interval (CI). Mean of continuous variables were summa-
rized with 95 % CI. Comparisons of means were investi-
gated by T-test and ANOVA. The Pearson Chi-square test
was used to analyze categorical variables. The logistic
regression was performed to assess the association be-
tween breakfast frequency and psychiatric distress and
violent behaviors in different models for adjusting possi-
ble confounders. The method of sampling (cluster sam-
pling) was considered in all statistical analysis. The sig-
nificant level was P value < 0.05.
Results
The participation rate was 90.6 %, and the sample consisted of
13,486 Iranian students with a mean age of 12.5 y (CI 95 %:
12.3, 12.6) and consisted of 50.76 % boys and 49.24 % girls.
Of participants, 2537(18.9 %), 1771(13.2 %) and
9119(67.9 %) were breakfast skippers, semi-skippers and
non-skippers, respectively. Table 1 shows the participants’
characteristics by gender.
The prevalence of psychiatric distress and violent behav-
iors according to sex and region is shown in Table 2. The
prevalence of psychiatric distress among was between 8.6 %
(CI 95 %: 8.0, 9.2) and 37.7 % (CI 95 %: 36.5, 38.9). The
most prevalent psychiatric distress reported by Iranian stu-
dents was angriness (37.7 %, CI 95 %: 36.5, 38.9) and the
least was confusion (8.6 %, CI 95 %: 8.04, 9.2). The psychi-
atric distress was significantly more prevalent among girls
than boys. Girls reported higher frequency of worthless
(12.2 % vs. 8.62 %), angriness (40.2 % vs. 35.35 %), anxiety
(28.87 % vs. 21.63 %), worried (35.35 % vs. 23.71 %), and
depression (22.88 % vs. 19.17 %) than boys did. Students
living in urban areas reported more psychiatric distress than
rural inhabitants (P value < 0.001).
The prevalence of violent behaviors ranged from
17.5 % (CI 95 %: 16.7, 18.4) to 39.9 % (CI 95 %: 38.6,
41.2). The violent behaviors were significantly more fre-
quent in boys than in girls. The prevalence of violent
behaviors was not significantly different among students
living in urban and rural areas.
The prevalence of psychiatric distress and violent behav-
iors according to breakfast frequency is shown in Table 3. The
percentage of psychiatric distress was 13.4–50.4 % among
breakfast skippers, 10.1–41.9 % in semi-skippers, and 7.0–
33.3 % in non-skippers. The frequency of psychiatric distress
was highest among breakfast skippers followed by semi-
skippers and non-skippers (P value < 0.001). Significant de-
creasing trend was observed in the prevalence of psychiatric
distress from breakfast skippers to non-skippers.
The frequency of violent behaviors was significantly higher
among breakfast skippers than non-skippers. Students who
skipped breakfast had higher frequency of being victim
(29.2 % vs. 26.7 %), bullying (21.0 % vs. 16.2 %), and physical
fight (42.6 % vs. 38.5 %) than their other counterparts.
Students who skipped breakfast had more prolonged screen
time (21.6 % vs. 17.4 %), less physical activity (33.5 % vs.
38.0 %), and lower sleep duration (72.0 % vs. 78.2 %) than
non-skippers. Breakfast skippers tended to smoke more than
non-skippers (39.9 % vs. 32.6 %). Non-skippers had lower
BMI (18.4 kg/m2 vs. 19.8 kg/m2), and more appropriate body
image (47.8 % vs. 42.3 %) than skippers.
The odd ratios for psychiatric distress across breakfast con-
sumption categories are shown in Table 4. The students who
skipped breakfast had a significantly higher risk of psychiatric
distress. They had a significantly higher risk of worthless (OR
1.77, CI 95 %:1.53–2.04), angriness (OR 1.67, CI 95 %:1.50–
1.86), worried (OR 1.46, CI 95 %:1.30–1.63), insomnia (OR
1.58, CI 95 %:1.39–1.80), confusion (OR 1.68, CI 95 %:1.43–
1.97), depression (OR 1.53, CI 95 %:1.36–1.72), and anxiety
(OR 1.62, CI 95 %:1.44–1.81). Also they had a significantly
higher risk of violent behaviors and of being victim (OR 1.12,
CI 95 %:1.00–1.26), bullying (OR 1.23, CI 95 %:1.07–1.40)
and physical fight (OR 1.21, CI 95 %:1.09–1.35).
 Indian J Pediatr

Table 1 Participants’
characteristics by gender: The Boys Girls Total
CASPIAN-IV study
Age (Year) 12.36(12.1–12.6)a 12.5(12.3–12.8) 12.4(12.2–12.64)
BMI (Kg/m2) 18.7(18.5–18.9) 18.9(18.7–19.1) 18.8(18.7–18.9)
Sweetened beverages (%)
Seldom 27.9(26.5–29.3)b 36.2(34.7–37.7) 32.0(30.9–33.0)
Weekly 49.5(48.0–50.9) 46.1(44.7–47.6) 47.8(46.8–48.9)
Daily 22.5(21.3–23.8) 17.6(16.4–18.7) 20.1(19.2–21.0)
Breakfast eating
Skippers 15.4(14.5–16.2) 22.5(21.4–23.5) 18.9(18.2–19.5)
Semi-skippers 13.0(12.1–13.8) 13.4(12.5–14.2) 13.2(12.6–13.7)
Non-skippers 71.6(70.5–72.6) 64.1(62.9–65.2) 67.9(67.1–68.7)
Screen time
≤2 h/d 78.0(76.6–79.4) 84.7(83.6–85.8) 81.3(80.4–82.2)
>2 h/d 21.9(20.5–23.4) 15.2(14.1–16.4) 18.6(17.7–19.5)
Physical activity
Mild 28.7(26.8–30.7) 39.6(37.5–41.7) 34.1(32.6–35.5)
Moderate 35.6(34.1–37.1) 37.9(36.3–39.6) 36.7(35.6–37.9)
Vigorous 35.6(33.6–37.6) 22.4(20.8–24.1) 29.1(27.7–30.4)
SES
Low 33.1(31.1–35.2) 33.7(31.7–35.8) 33.4(32.0–34.9)
Intermediate 32.6(31.1–34.2) 33.5(32.0–35.0) 33.0(32.0–34.1)
High 34.1(31.8–36.5) 32.7(30.4–35.0) 33.4(31.8–35.0)
Sleep duration
<5 h/d 0.5(0.4–0.8) 0.7(0.5–0.9) 0.6(0.5–0.8)
5–8 h/d 22.3(20.9–23.9) 22.9(21.4–24.4) 22.6(21.5–23.7)
>8 h/d 77.0(75.4–78.5) 76.3(74.8–77.8) 76.7(75.5–77.7)
Smoking status
Passive smoker 35.2(33.7–36.8) 33.7(32.2–35.1) 34.4(33.4–35.5)
Active smoker 3.4(2.9–4.1) 1.6(1.3–2.0) 2.5(2.2–2.9)
Body image
Lean 34.2(32.8–35.6) 34.1(32.7–35.6) 34.2(33.2–35.2)
Normal 49.0(47.6–50.3) 44.1(42.7–45.5) 46.5(45.5–47.6)
Obese 16.7(15.7–17.7) 21.7(20.5–22.9) 19.1(18.4–19.9)

BMI Body mass index; SES Socioeconomic status

a
Mean ± 95%CI, b N (95%CI)

Table 2 The prevalence of psychiatric distress and violent behaviors according to gender and living area: The CASPIAN-IV study

Gender Living area Total

Boys Girls P value Urban Rural P value

Psychiatric distress
Worthless 8.6(7.8–9.4)a 12.2(11.2–13.2) <0.001 11.0(10.3–11.8) 8.2(7.0–9.6) <0.001 10.3(9.7–11.0)
Angriness 35.3(33.6–37.0) 40.2(38.4–42.0) 0.0001 39.5(38.0–40.9) 32.2(29.7–34.8) <0.001 37.7(36.5–38.9)
Worried 23.7(22.2–25.2) 35.3(33.5–37.2) <0.001 32.4(31.0–33.8) 20.2(18.1–22.5) <0.001 29.4(28.2–30.7)
Insomnia 15.0(13.9–16.2) 17.1(15.8–18.3) 0.01 17.0(16.0–18.0) 12.9(11.3–14.6) <0.001 16.0(15.2–16.9)
Confusion 7.8(7.0–8.7) 9.4(8.5–10.4) 0.01 8.8(8.1–9.6) 7.9(6.7–9.2) 0.2 8.6(8.0–9.2)
Depression 19.1(17.9–20.5) 22.8(21.4–24.3) 0.0001 22.5(21.4–23.6) 16.2(14.4–18.1) <0.001 20.9(20.0–21.9)
Anxiety 21.6(20.2–23.0) 28.8(27.3–30.4) <0.001 26.6(25.4–27.9) 20.7(18.6–22.9) <0.001 25.2(24.1–26.2)
Violent behaviors
Victim 29.4(28.0–30.9) 25.2(23.8–26.6) <0.001 27.4(26.3–28.6) 26.9(24.7–29.2) 0.6 27.3(26.3–28.4)
Bully 20.7(19.5–21.9) 14.3(13.2–15.4) <0.001 17.5(16.5–18.4) 17.7(16.0–19.6) 0.8 17.5(16.7–18.4)
Physical fight 48.4(46.7–50.0) 31.1(29.5–32.8) <0.001 39.7(38.3–41.1) 40.5(37.9–43.1) 0.6 39.9(38.6–41.2)
a
% (CI 95 %), P value < 0.05 is significant
Indian J Pediatr

Table 3 Participants’
characteristics according to Breakfast frequency
breakfast frequency: The
CASPIAN-IV study Skipper Semi-skipper Non-skipper P valuea

Worthless 16.5(15.0–18.1)b 12.3(10.7–14.0) 8.3(7.6–9.0) <0.001

Angriness 50.4(48.1–52.7) 41.9(39.4–44.5) 33.3(32.0–34.7) <0.001
Worried 38.8 (36.7-41.0) 35.5(32.9–38.1) 25.7(24.4–27.0) <0.001
Insomnia 22.5(20.8–24.3) 18.5(16.7–20.5) 13.7(12.8–14.7) <0.001
Confusion 13.4(12.0–14.9) 10.1(8.7–11.6) 7.0(6.4–7.6) <0.001
Depression 28.7(26.8–30.7) 22.9(20.9–25.0) 18.4(17.4–19.5) <0.001
Anxiety 34.6(32.5–36.8) 31.4(29.0–33.8) 21.3(20.2–22.4) <0.001
Victim 29.2(27.3–31.2) 27.9(25.7–30.2) 26.7(25.5–27.9) 0.04
Bully 21.0(19.3–23.0) 19.2(17.2–21.2) 16.2(15.3–17.2) <0.001
Physical fight 42.6(40.4–44.7) 43.1(40.5–45.7) 38.5(37.1–40.0) 0.0001
BMI (Kg/m2) 19.8(19.5–20.0)c 19.3(19.0–19.5) 18.4(18.3–18.6) <0.001
Sleep duration
<5 h/d 1.0(0.7–1.5)b 0.5(0.2–0.9) 0.5(0.4–0.7)
5–8 h/d 26.8(24.9–28.8) 24.1(21.9–26.4) 21.1(19.9–22.4) <0.001
>8 h/d 72.0(70.0–74.0) 75.3(72.9–77.5) 78.2(77.0–79.4)
Physical activity
Mild 41.8(39.3–44.3) 38.4(35.8–41.1) 31.1(29.5–23.6)
Moderate 33.5(31.4–35.6) 35.1(32.8–37.4) 38.0(36.7–39.3) <0.001
Vigorous 24.6(22.6–26.7) 26.4(24.1–28.8) 30.8(29.3–32.4)
Screen time
≤2 h/d 78.3(76.4–80.0) 79.4(77.3–81.4) 82.6(81.5–83.5) <0.001
>2 h/d 21.6(19.9–23.5) 20.5(18.5–22.6) 17.4(16.4–18.4)
SES
Low 36.9(34.4–39.4) 33.1(30.5–35.8) 32.5(30.9–34.1)
Intermediate 32.7(30.7–34.8) 34.7(32.3–37.3) 32.8(31.5–34.0) 0.0005
High 30.2(27.8–32.8) 32.0(29.4–34.8) 34.6(32.8–36.5)
Smoking status
Passive smoker 39.9(37.8–42.0) 36.7(34.4–39.0) 32.6(31.4–33.7) <0.001
Active smoker 4.1(3.3–5.0) 3.1(2.4–4.1) 2.0(1.7–2.4) <0.001
Sweetened beverages (%)
Seldom 30.5(28.5–32.5) 29.2(27.0–31.5) 32.9(31.7–34.2)
Weekly 45.4(43.4–47.7) 51.2(48.7–53.6) 47.9(46.7–49.1) <0.001
Daily 24.0(22.3–25.8) 19.5(17.6–21.6) 19.1(18.1–20.1)
Body image
Lean 32.6(30.7–34.7) 33.4(31.0–35.9) 34.7(33.5–35.9)
Normal 42.3(40.2–44.3) 46.0(43.6–48.4) 47.8(46.6–49.1) <0.001
Obese 25.0(23.3–26.8) 20.4(18.5–22.5) 17.3(16.4–18.2)

BMI Body mass index; SES Socioeconomic status

a
p values are resulted from analysis of variance (ANOVA), b % (CI 95 %), c Mean ± CI 95 %, P value < 0.05 is
significant

Discussion
The goal of this study was to investigate the association of break-
fast intake with psychiatric distress and violent behaviors in
Iranian children and adolescents. The main results of the present
study showed significant association between breakfast skipping
and mental health disorders, independent of the baseline
characteristics such as age, sleep duration, screen time, and body
image. Students who regularly consumed breakfast were less
likely to experience mental health disorders.
The index findings support and extent the results of the pre-
vious studies in which breakfast skipping has been associated
with psychiatric distress and violent behaviors among children
and adolescents [13, 22, 23]. The present findings are consistent
 Indian J Pediatr

Table 4 Odds ratios (CI 95 %)

for psychiatric distress and violent Breakfast frequency
behaviors across breakfast
frequency: The CASPIAN-IV Non-skipper Semi-skipper Skipper P value
study
Worthless
Model Ia 1 1.54(1.31–1.82)* 2.18(1.91–2.48)* <0.001
Model IIb 1 1.39(1.18–1.63)* 1.88(1.65–2.15)* <0.001
Model IIIc 1 1.33(1.12–1.59)* 1.77(1.53–2.04)* <0.001
Angriness
Model I 1 1.44(1.29–1.61)* 2.03(1.84–2.24)* <0.001
Model II 1 1.33(1.18–1.49)* 1.83(1.66–2.02)* <0.001
Model III 1 1.26(1.11–1.42)* 1.67(1.50–1.86)* <0.001
Worried
Model I 1 1.59(1.41–1.79)* 1.83(1.66–2.03)* <0.001
Model II 1 1.41(1.25–1.59)* 1.51(1.36–1.68)* <0.001
Model III 1 1.40(1.23–1.59)* 1.46(1.30–1.63)* <0.001
Insomnia
Model I 1 1.42(1.24–1.63)* 1.82(1.62–2.05)* <0.001
Model II 1 1.29(1.13–1.48)* 1.61(1.43–1.82)* <0.001
Model III 1 1.24(1.07–1.44)* 1.58(1.39–1.80)* <0.001
Confusion
Model I 1 1.48(1.24–1.77)* 2.05(1.77–2.38)* <0.001
Model II 1 1.34(1.12–1.61)* 1.82(1.56–2.11)* <0.001
Model III 1 1.21(0.99–1.47) 1.68(1.43–1.97)* <0.001
Depression
Model I 1 1.31(1.16–1.48)* 1.77(1.60–1.97)* <0.001
Model II 1 1.17(1.03–1.32)* 1.54(1.38–1.71)* <0.001
Model III 1 1.17(1.02–1.34)* 1.53(1.36–1.72)* <0.001
Anxiety
Model I 1 1.68(1.50–1.89)* 1.95(1.75–2.17)* <0.001
Model II 1 1.51(1.34–1.71)* 1.67(1.50–1.85)* <0.001
Model III 1 1.49(1.31–1.70)* 1.62(1.44–1.81)* <0.001
Victim
Model I 1 1.06(0.94–1.19) 1.13(1.02–1.25)* 0.01
Model II 1 1.09(0.97–1.23) 1.19(1.07–1.33)* 0.001
Model III 1 1.02(0.90–1.16) 1.12(1.00–1.26)* 0.054
Bully
Model I 1 1.22(1.06–1.40)* 1.37(1.21–1.55)* <0.001
* *
Model II 1 1.20(1.05–1.39) 1.40(1.24–1.59) <0.001
Model III 1 1.07(0.9–1.24) 1.23(1.07–1.40)* 0.003
Physical fight
Model I 1 1.20(1.08–1.34)* 1.18(1.07–1.30)* <0.001
Model II 1 1.24(1.10–1.38)* 1.29(1.17–1.42)* <0.001
Model III 1 1.18(1.04–1.33)* 1.21(1.09–1.35)* <0.001
a
Without adjusted (crude models), b Adjusted for age, sex and life location, c Additionally adjusted for screen
time, physical activity, socioeconomic status, passive and active smoking, body image, sweetened beverages, and
BMI
*
P < 0.05

with some previous studies; Smith has suggested that regular et al. have reported the association between cyber bullying,
consumption of breakfast enhances mental health and reduces school bullying and breakfast skipping among 11–20 y-old stu-
stress by decreasing cortisol levels [24–27]. Sampasa-Kanyinga dents [13]. Moreover, it is shown that the influence of breakfast
Indian J Pediatr
skipping on mental distress and academic performance is stron-
ger for boys than girls [23].
Regular breakfast intake is a key point in the association
between breakfast eating and mental health. Definitely, regu-
larity is a major factor in the lifestyle. It is shown that adoles-
cents with regular consumption of breakfast and other meals
have more healthy dietary behaviors than others [23, 28].
Iranian breakfast usually contains bread, cheese or butter or
egg, as well as drinks, mainly tea and milk. These foods com-
prise of many macronutrients and micronutrients that may have
beneficial effects on mental well being. Some studies have sug-
gested that intake of essential fatty acids and other micronutrients
may prevent mental health disorders [29–32]. The other nutrient
is glucose, which is known as a vital effective element for tryp-
tophan synthesis. Tryptophan is a vital protein in the formation
of serotonin, which is involved in mood regulation [33, 34].
The current study has some limitations. The main one is the
cross-sectional design, which caused restriction of follow up
and assuming causal relationships; therefore, longitudinal and
interventional surveys are needed to document the effects of
regular intake of breakfast on mental health. Despite these
limitations, the major strength of this study is the large nation-
al sample size, representing the Iranian children and adoles-
cents’ population. Moreover, using an international and valid
questionnaire with high quality control of data gathering are
other strengths of this study. Furthermore, the analyses were
adjusted for potential confounding variables including some
lifestyle habits and socioeconomic factors.
Conclusions
The present findings serve as confirmatory evidence that reg-
ular breakfast intake may decrease the risk of mental health
disorders and violent behaviors in children and adolescents.
Adhering to a regular and balanced diet, besides the awareness
of parents on the importance of breakfast eating, may be an
appropriate approach for prevention of mental health disorders
and violent behaviors.
Acknowledgments This nationwide survey was conducted in Iran with
corporation of the Ministry of Health and Medical education; Ministry of
Education and Training, Child Growth and Development Research
Center, Isfahan University of Medical Sciences; and Endocrinology and
Metabolism Research Center of Tehran University of Medical Sciences.
Contributions All authors read and approved the final manuscript. RH
will act as guarantor for the paper.
Compliance with Ethical Standards
Conflict of Interest None.
Source of Funding None.
Ethical Approval Ethical approval was obtained for the main study, no
approval has been sought for this research.
References
1. Atlas: Child and Adolescent Mental Health Resources. Geneva:
World Health Organization; 2005.
2. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of
mental disorders in US adolescents: results from the National
Comorbidity Survey Replication–Adolescent Supplement (NCS-
A). J Am Acad Child Adolesc Psychiatry. 2010;49:980–9.
3. Belfer ML. Child and adolescent mental disorders: the magnitude
of the problem across the globe. J Child Psychol Psychiatry.
2008;49:226–36.
4. Prince M, Patel V, Saxena S, et al. No health without mental health.
Lancet. 2007;370:859–77.
5. Nansel TR, Craig W, Overpeck MD, Saluja G, Ruan WJ; Health
Behaviour in School-aged Children Bullying Analyses Working
Group. Cross-national consistency in the relationship between bul-
lying behaviors and psychosocial adjustment. Arch Pediatr Adol
Med. 2004;158:730–6.
6. Kumpulainen K, Räsänen E. Children involved in bullying at ele-
mentary school age: their psychiatric symptoms and deviance in
adolescence: an epidemiological sample. Child Abuse Negl.
2000;24:1567–77.
7. Zinner SH, Conelea CA, Glew GM, Woods DW, Budman CL. Peer
victimization in youth with Tourette syndrome and other chronic tic
disorders. Child Psychiatry Hum Dev. 2012;43:124–36.
8. Craig WM. The relationship among bullying, victimization, depres-
sion, anxiety, and aggression in elementary school children.
Personal Individ Differ. 1998;24:123–30.
9. Kumpulainen K, Räsänen E, Puura K. Psychiatric disorders and the
use of mental health services among children involved in bullying.
Aggress Behav. 2001;27:102–10.
10. Oddy WH, Robinson M, Ambrosini GL, et al. The association
between dietary patterns and mental health in early adolescence.
Prev Med. 2009;49:39–44.
11. Samieri C, Jutand MA, Feart C, Capuron L, Letenneur L,
Barberger-Gateau P. Dietary patterns derived by hybrid clustering
method in older people: association with cognition, mood, and self-
rated health. J Am Diet Assoc. 2008;108:1461–71.
12. Vereecken C, Dupuy M, Rasmussen M, et al; HBSC Eating &
Dieting Focus Group. Breakfast consumption and its socio-
demographic and lifestyle correlates in schoolchildren in 41 coun-
tries participating in the HBSC study. Int J Public Health. 2009;54:
180–90.
13. Sampasa-Kanyinga H, Roumeliotis P, Farrow CV, Shi YF.
Breakfast skipping is associated with cyberbullying and school
bullying victimization. A school-based cross-sectional study.
Appetite. 2014;79:76–82.
14. Timlin MT, Pereira MA, Story M, Neumark-Sztainer D. Breakfast
eating and weight change in a 5-year prospective analysis of ado-
lescents: project EAT (Eating Among Teens). Pediatrics. 2008;121:
e638–45.
15. Pollitt E, Mathews R. Breakfast and cognition: an integrative sum-
mary. Am J Clin Nutr. 1998;67:804S–13S.
16. Lombard C. What is the role of food in preventing depression and
improving mood, performance and cognitive function? Med J Aust.
2000;173:S104–5.
17. Farrow CV, Fox CL. Gender differences in the relationships be-
tween bullying at school and unhealthy eating and shape‐related
attitudes and behaviours. Br J Educ Psychol. 2011;81:409–20.

18. Kelishadi R, Ardalan G, Qorbani M, et al. Methodology and early
findings of the fourth survey of childhood and adolescence surveil-
lance and prevention of adult non-communicable disease in Iran:
the CASPIAN-IV study. Int J Prev Med. 2013;4:1451–60.
19. Association WM. Declaration Of Helsinki—Ethical Principles for
Medical Research Involving Human Subjects,(amended by the 59th
WMA General Assembly, Seoul, October 2008). 2009.
20. Kelishadi R, Majdzadeh R, Motlagh M-E, et al. Development and
evaluation of a questionnaire for assessment of determinants of
weight disorders among children and adolescents: the Caspian-IV
study. Int J Prev Med. 2012;3:699–705.
21. Caro DH, Cortés D. Measuring family socioeconomic status: an
illustration using data from PIRLS 2006. IERI Monograph Series.
Issues and Methodol Large Scale Assessments. 2012;5:9–33.
22. O’Sullivan TA, Robinson M, Kendall GE, et al. A good-quality
break fast is associated with better mental health in adolescence.
Public Health Nutr. 2009;12:249–58.
23. Lien L. Is breakfast consumption related to mental distress and
academic performance in adolescents? Public Health Nutr.
2007;10:422–8.
24. Smith AP. Breakfast and mental health. Int J Food Sci Nutr.
1998;49:397–402.
25. Smith AP. Breakfast cereal consumption and subjective reports of
health. Int J Food Sci Nutr. 1999;50:445–9.
Indian J Pediatr
26. Smith AP. Breakfast cereal consumption and subjective reports of
health by young adults. Nutr Neurosci. 2003;6:59–61.
27. Smith AP. Stress, breakfast cereal consumption and cortisol. Nutr
Neurosci. 2002;5:141–4.
28. Johansen A, Rasmussen S, Madsen M. Health behaviour among
adolescents in Denmark: influence of school class and individual
risk factors. Scand J Public Health. 2006;34:32–40.
29. Bamber DJ, Stokes CS, Stephen AM. The role of diet in the pre-
vention and management of adolescent depression. Nutr Bull.
2007;32:90–9.
30. Salem N Jr, Litman B, Kim HY, Gawrisch K. Mechanisms of action
of docosahexaenoic acid in the nervous system. Lipids. 2001;36:
945–59.
31. Benton D, Haller J, Fordy J. Vitamin supplementation for 1 year
improves mood. Neuropsychobiol. 1995;32:98–105.
32. Silvers KM, Scott KM. Fish consumption and self-reported physi-
cal and mental health status. Public Health Nutr. 2002;5:427–31.
33. Bravo R, Matito S, Cubero J, et al. Tryptophan-enriched cereal
intake improves nocturnal sleep, melatonin, serotonin, and total
antioxidant capacity levels and mood in elderly humans. Age
(Dordr). 2013;35:1277–85.
34. Wallin MS, Rissanen AM. Food and mood: relationship between
food, serotonin and affective disorders. Acta Psychiatr Scand
Suppl. 1994;377:36–40.