'Breakfast: how important is it really?' A response.

'Breakfast: how important is it really?' A response Madam First, we would like to thank the author of a recent Letter to the Editor (1) for his positive overall comments on our study (2,3) and for acknowledging that the findings are written with great care. While the letter moves beyond our paper to critique the wider literature surrounding the relationship between breakfast and health outcomes, such as obesity, we respond here only to those issues raised in relation to our paper. The letter rightly highlights that association does not equal causality. In our communications with the media, we consciously resisted the use of overly strong causal language for this reason. It will never be possible to randomly assign children to eat or not eat breakfast, and track their outcomes for 12–18 months in order to firmly attribute causality to breakfast itself. In the absence of such evidence, the longitudinal observational design of our study serves as the most robust form of evidence available. Of course, there remains a possibility that unmeasured confounders, such as family functioning, and clustering with other behaviours may contribute to the observed associations. Issues such as these have been debated at length with regard to breast-feeding, which continues to be strongly recommended by the public health community as providing the healthiest start in life; a paper published in 2014 in Social Science & Medicine (4) , for example, showed that where comparisons are made between siblings who are or are not breast-fed, estimates of effects of breast-feeding on young people's well-being were substantially reduced. The author suggests that 'consumption of breakfast at home is a marker for the quality of a child's home environment and parenting … Indeed, consumption of breakfast may be a particularly good marker in this respect, better for example than free-school-meal (FSM) entitlement … as it may reflect well at an individual level the motivation and capacity of caregivers to provide a nurturing environment for their children' (1). This alternative set of hypotheses is essentially premised on an assumption that a child's consumption of breakfast is explained by 'good parenting'. However while on the face of it, it seems plausible that parenting might contribute to this association, is the hypothesis that this fully explains the observed associations grounded in evidence? Within the letter, the above argument is advanced without any reference to the scientific literature. We would argue that the underlying assumption …