Increasing Egg Consumption at Breakfast Is Associated with Increased Usual Nutrient Intakes: A Modeling Analysis Using NHANES and the USDA Child and Adult Care Food Program School Breakfast Guidelines

Papanikolaou Y ,Fulgoni V ,20 April 2021 ,Increasing Egg Consumption at Breakfast Is Associated with Increased Usual Nutrient Intakes: A Modeling Analysis Using NHANES and the USDA Child and Adult Care Food Program School Breakfast Guidelines ,Journal of Human Nutrition ,doi: https://www.mdpi.com/journal/nutrients

Abstract: 

The objective of the current modeling analysis was three-fold: (1) to examine usual nutrient
intakes in children when eggs are added into dietary patterns that typically do not contain eggs; (2) to
examine usual nutrient intakes with the addition of eggs in the Child and Adult Care Food Program
(CACFP) school breakfast; and (3) to examine nutrient adequacy when eggs are included in routine
breakfast patterns and with the addition of eggs to the CACFP school breakfast program. Dietary
recall data from the National Health and Nutrition Examination Survey 2011–2016 (children aged
1–18 years-old; n = 9254; CACFP n = 159) were used in the analysis. The usual intakes of pantothenic
acid, riboflavin, selenium, and vitamin D increased 10 percent (relative to the baseline values) with
the addition of one egg at breakfast. The usual intakes of protein and vitamin A at breakfast were
also increased by more than 10 percent compared to the baseline values with the addition of two
eggs. Similar outcomes were observed with the addition of eggs to the CACFP school breakfast. The
percent of children above the adequate intake for total choline increased to 43.6 and 57.8% with one
and two eggs, respectively, compared to 22.6% at the baseline. The addition of eggs at breakfast can
contribute to nutrient intakes and overall dietary adequacy and play a role in public health initiatives
aimed at increasing the intake of under-consumed nutrients and nutrients of concern.
Keywords: US National Health and Nutrition Examination Survey (NHANES); eggs; children;
breakfast; CACFP; usual intakes; nutrient adequacy
1. Introduction
The importance of breakfast has been well documented in the scientific literature;
however, large portions of Americans are still not eating breakfast [1]. Consumer survey
data show that as many as 31 million Americans do not consume any foods before the lunch
period. In children, the highest incidence for breakfast skipping is linked to adolescents,
with 14% of 13- to 17-year-olds reporting no food consumption before lunch [2]. Indeed,
this raises public health concerns, as breakfast consumption in children has previously
been shown to be a key contributor to nutrient density and overall diet quality. Data
from the UK National Diet and Nutrition Survey Rolling Programme demonstrated that
children who frequently consume breakfast had significantly greater intakes of dietary fiber,
folate, calcium iron, and iodine relative to those who skipped breakfast. Further analyses
showed that higher percentages of breakfast consuming children met nutrient-specific
recommendations compared to children who skipped breakfast [3]. Data from the US
National Health and Nutrition Examination Survey (NHANES) has identified associations
with breakfast skipping and all-cause mortality, in that skipping breakfast was associated
with an 87% increased risk for cardiovascular mortality and an 19% increased risk for
Nutrients 2021, 13, 1379. https://doi.org/10.3390/nu13041379 https://www.mdpi.com/journal/nutrients
Nutrients 2021, 13, 1379 2 of 9
all-cause mortality [4]. A recent meta-analysis of eight observational studies also showed
that breakfast skipping was related to an elevated risk of type 2 diabetes [5].
In the US, public health and nutrition initiatives have focused on providing access
to breakfast to vulnerable populations, with the creation of the Child and Adult Care
Food Program (CACFP)—a nutrition-focused meal program that is operated at the US
federal level, wherein reimbursements are provided to eligible children and adults enrolled
for care at approved centers, including family day care homes, group child care centers,
emergency shelters, and afterschool programs [6]. Detailed criteria have been established
for what can be served at meals, and they can be food specific. For example, yogurt must
contain no more than 23 g of sugar per each 6 ounce serving, or 3.83 g of sugar per ounce.
Cooking methods are also specified, such that healthy cooking includes roasting, baking,
sautéing, and steaming, but does not allow for deep fat frying [6]. The USDA has updated
and revised the CACFP meal patterns to ensure that children and adolescents have access
to healthy, balanced meals at breakfast and throughout the day [6]. Effective in 2017,
requirements in the CACFP meal patterns allowed for meat and meat alternatives to be
served in place of the entire grains component at breakfast [7]. Meat and meat alternatives
at breakfast include beans, cheese, eggs, lean meat/poultry/fish, nut butters, tofu, and
yogurt, with standards set in place for minimum serving amounts at breakfast that are
dependent on age group. For example, the minimum amount of eggs that can be served in
place of the entire grains component at breakfast for children 1- to 5- and 6- to 18-years-old
are one-fourth and one-half of a large egg at breakfast, respectively, to a maximum of three
times/week. Similarly, the 2020–2025 Dietary Guidelines for Americans (DGA 2020–2025)
also promote a variety of protein foods (which include eggs), particularly when consumed
with limited sodium, solid fat, and added sugar [8]. The Dietary Guidelines Scientific
Advisory Committee (DGAC 2020) includes eggs as an introductory food for infants and
as part of a healthy dietary pattern in all children [9]. As eggs have been previously
established to be a nutrient-dense food, with one 50 g serving (i.e., one egg) contributing
several bioactive components and essential nutrients that are routinely underconsumed
with current eating patterns.
Recent published data in children show the dietary benefits of eggs within overall
eating patterns [10–12]; however, limited data are available that have examined the outcomes
associated with the addition of eggs to the breakfast meal. Therefore, the purpose
of the current modeling analysis was three-fold: (1) to examine usual nutrient intakes in
children when eggs are added into dietary patterns that typically do not contain eggs; (2)
to examine usual nutrient intakes with the addition of eggs in CACFP school breakfast;
and (3) to examine nutrient adequacy when eggs are included in routine breakfast patterns.
2. Experimental Section
Data for the current analyses were obtained from NHANES, a US cross-sectional, nationally
representative sample, which includes children ages 1- to 18-years-old. NHANES is
a continuous study governed by the Centers for Disease Control and Prevention (CDC) and
samples free-living Americans (i.e., noninstitutionalized) every 2 years [13]. The requisite
ethical protocols, including informed consent from the study participants, were previously
obtained, approved, and documented by the CDC ethic boards. Three datasets were combined
for the present study (NHANES 2011–2012, 2013–2014, and 2015–2016) [14–16]. Data
for the nutrients examined are from the U.S. Department of Agriculture (USDA) Food
and Nutrient Database for Dietary Studies (FNDDS) database for NHANES [17]. The
FNDDS databases determine food and beverage nutrient values in WhatWe Eat in America
(WWEIA), which represents the dietary intake component of NHANES. The collection
procedure for WWEIA involves use of the Automated Multiple Pass Method (AMPM),
representing a dietary collection tool that provides a valid, evidence-based approach for
gathering data for national dietary surveys. The accuracy, effectiveness, and efficiency of
the AMPM method have been comprehensively described and previously published [18].
Nutrients 2021, 13, 1379 3 of 9
2.1. Nutrient Intake Modeling Scenarios
NHANES 2011–2016 dietary recall and questionnaire data were obtained for subjects
aged 1-to 18-years-old, with exclusions for incomplete data (n = 9254 subjects). Data interpreted
to be reliable was comprised of 24 h of completed recalled dietary data. Pregnant
and lactating females were not included in the analysis. Nutrient intakes were examined
for the following modeling scenarios:
Baseline: No changes to the typical breakfast pattern
Model 1: Addition of one egg to breakfast when no eggs were typically consumed at
breakfast
Model 2: Addition of two eggs at breakfast when no eggs were typically consumed at
breakfast
Model 3: Addition of one egg at breakfast when breakfast is CACFP compliant
Model 4: Addition of two eggs to breakfast when breakfast is CACFP compliant
Breakfast was determined as CACFP compliant if fluid milk, vegetables/fruit, and
grains quantities satisfied the following USDA criteria:
Milk: 4 oz unflavored whole milk (age 1 year), 4 oz unflavored 1% or skim milk
(age 2 years), 6 oz unflavored 1% or skim milk (age 3–5 years), 8 oz unflavored 1% or skim
milk or flavored skim milk (age 6–18 years)
Fruit/Vegetables: 0.25 oz eq (age 1–2 years), 0.5 oz eq (age 3–18 years)
Grain: 0.5 oz eq (age 1–5 years), 1.0 oz eq (age 6–18 years)
The definition of egg consumption within the modeling scenarios included 1 oz eq
eggs from whole eggs, boiled eggs, or poached eggs. Nutrient profiles for 1 oz eq egg
were used to determine nutrient intakes when eggs were added to breakfast in the four
modeling scenarios. Egg intake was determined by FNDDS food codes defined in the
appropriate WWEIA category (with the exclusion of ‘egg substitutes’, and ‘other poultry
eggs’). The present study did not include egg-containing or grain-based mixed dishes
(i.e., egg-containing sandwiches, breakfast burritos, and all egg-containing bakery foods,
including cakes, breads, cookies, and biscuits).
2.2. Methodolgy
Statistical procedures were completed with the employment of SAS software (Version
9.4, SAS Institute, Cary, NC, USA). The investigation used day 1 dietary survey weights
to develop nationally representative estimates for children and adolescents, along with
adjustment for the complex sample design of the database. Usual intake was estimated
using the National Cancer Institute method, version 2.1 and has been published previously
by our group [12,19]. Means (standard errors) for daily nutrient intakes were determined
for baseline scenarios and all modeling scenarios. For select nutrients where an established
estimated average requirement (EAR) is available, nutrient inadequacy was calculated
(i.e., percent below EAR) for all children. Similarly, where nutrients have an authoritative
adequate intake (AI), nutrient adequacy was determined (i.e., percent above AI) for all
children where a sufficient sample size was available. Nutrient inadequacies/adequacies’
percentages, standard errors, and lower/upper and 95th confidence levels for select nutrients
were determined. When 95th confidence levels did not overlap, we deemed the
changes to be meaningful.
3. Results
3.1. Nutrient Usual Intakes with the Addition of Eggs at Breakfast
Current daily nutrient usual intakes are presented in Table 1. Additionally, the usual
intakes for macro- and micro-nutrients when modeling the various scenarios are presented
in Table 1. In modeling the addition of one and two eggs at breakfast, the usual intakes
of total choline, lutein + zeaxanthin, docosahexanoic acid, vitamin D, vitamin B5, and
cholesterol increased by greater than 10 percent (relative to the baseline). Furthermore, the
addition of one and two eggs at breakfast increased the usual intakes of cholesterol, lutein
Nutrients 2021, 13, 1379 4 of 9
+ zeaxanthin, docosahexaenoic acid, and total choline by 20 percent over baseline (see
Table 1).
Table 1. Effects of the inclusion of eggs in breakfast on the usual intake of nutrients among children aged 1–18 years-old;
gender combined; US National Health and Nutrition Examination Survey (NHANES) 2011–2016; n = 9254.
Usual Intake
Nutrients Baseline SE Breakfast + 1 Egg SE Breakfast + 2
Eggs SE
(Scenario 0) (Scenario 1) (Scenario 2)
Calcium (mg) 1023 10 1039 11 1054 11
Carbohydrates (g) 244 2 244 2 245 2
Cholesterol (mg) 214 2 319 ** 3 421 ** 3
Dietary Fiber (g) 13.9 0.1 13.9 0.1 13.8 0.1
Energy (kcal) 1851 15 1891 15 1931 14
Energy from Sat Fat (%) 11.7 0.1 11.9 0.1 12.1 0.1
Folate DFE (mcg) 499 6 510 6 519 6
Iron (mg) 13.7 0.2 14.2 0.2 14.7 0.2
Lutein + Zeaxanthin
(mcg) 769 17 907 ** 17 1060 ** 19
Magnesium (mg) 231 2 234 2 238 2
Niacin (mg) 20.8 0.2 20.8 0.2 20.9 0.2
Pantothenic Acid (mg) 28.3 0.3 31.5 * 0.3 34.8 ** 0.4
PFA 18:2
(Octadecadienoic) (g) 13.7 0.2 14.1 0.2 14.6 0.2
PFA 18:3
(Octadecatrienoic) (g) 1.3 0.02 1.4 0.02 1.4 0.02
PFA 20:5
(Eicosapentaenoic) (g) 0.01 0.0003 0.01 0.0003 0.01 0.0003
PFA 22:6
(Docosahexaenoic) (g) 0.02 0.0008 0.04 ** 0.001 0.06 ** 0.001
Phosphorus (mg) 1247 10 1302 10 1359 10
Potassium (mg) 2146 17 2185 16 2222 16
Protein (g) 66.8 0.6 70.2 0.6 73.7* 0.6
Riboflavin (mg) 1.9 0.02 2.1 * 0.02 2.2 * 0.02
Selenium (mg) 93.9 1 102 * 1 111 ** 1
Sodium (mg) 2924 27 3046 27 3165 27
Thiamin (mg) 1.5 0.01 1.5 0.02 1.53 0.01
Total Choline (mg) 248 2 314 ** 3 379 ** 3
Total Fat (g) 69.8 0.6 72.3 0.7 75 0.7
Total Monounsaturated
Fat (g) 23.6 0.3 24.6 0.3 25.6 0.3
Total Polyunsaturaed Fat
(g) 15.4 0.2 15.9 0.2 16.4 0.2
Total Saturated Fat (g) 24.6 0.3 25.4 0.3 26.3 0.3
Total Sugars (g) 115 1 115 1 115 1
Trans Fat (g) 1.9 0.03 1.9 0.03 2 0.03
Vitamin A RAE (mcg) 594 8 640 9 683 * 9
Vitamin B12 (mcg) 4.7 0.1 4.9 0.1 5.1 0.1
Vitamin B6 (mg) 1.7 0.02 1.7 0.02 1.8 0.02
Vitamin C (mg) 74.2 1.7 74.2 1.7 74.1 1.7
Vitamin D (D2+D3) (mcg) 5.7 0.1 6.3 * 0.1 6.8 * 0.1
Vitamin E, as
alpha-tocopherol (mg) 6.9 0.1 7.2 0.1 7.5 0.1
Vitamin K (mg) 64.8 1.3 64.7 1.3 64.9 1.3
Zinc (mg) 9.8 0.1 10.1 0.1 10.5 0.1
* 10% higher vs. baseline; ** 20% higher vs. baseline; SE = standard error; PFA = polyunsaturated fatty acids.
3.2. Nutrient Usual Intakes with the Addition of Eggs to CACFP School Breakfast
Adding one and two eggs to the CACFP compliant breakfast resulted in meaningful
changes to usual nutrient intakes, relative to baseline nutrient intake. The addition of one
and two eggs to the CACFP school breakfast resulted in a 20 percent increase in usual
intake of cholesterol, docosahexaenoic acid, and total choline, while a 20% over the usual
intake was observed with lutein + zeaxanthin. Adding one egg to the CACFP breakfast
resulted in a 10% increase in vitamin A, vitamin D, and pantothenic acid (Table 2).
Nutrients 2021, 13, 1379 5 of 9
Table 2. Effect of inclusion of eggs in the Child and Adult Care Food Program (CACFP) school breakfast on the usual intake
of nutrients among children aged 1–18 years-old; gender combined; NHANES 2011–2016; n = 159.
Usual Intake
Nutrients Baseline CACFP SE CACFP + 1 Egg SE CACFP + 2 Eggs SE
(Scenario 3) (Scenario 4) (Scenario 5)
Calcium (mg) 1326 53 1341 53 1356 52
Carbohydrates (g) 252 12 252 11 253 11
Cholesterol (mg) 234 20 339 ** 17 444 ** 14
Dietary Fiber (g) 16.3 1 16.3 1 16.3 1
Energy (kcal) 1879 76 1924 75 1969 73
Energy from Sat
Fat (%) 11.1 0.5 11.5 0.5 11.7 0.5
Folate DFE (mcg) 555 37 565 37 576 36
Iron (mg) 15.1 1 15.7 1.1 16.2 1.1
Lutein +
Zeaxanthin (mcg) 995 126 1122 * 113 1279 ** 121
Magnesium (mg) 274 12 277 12 280 12
Niacin (mg) 20.7 1.2 20.8 1.2 20.8 1.2
Pantothenic Acid
(mg) 36.2 1.7 39.5 1.7 42.8 * 1.7
PFA 18:2
(Octadecadienoic)
(g)
13.1 0.7 13.5 0.7 14.1 0.7
PFA 18:3 (Octadecatrienoic)
(g)
1.3 0.1 1.3 0.1 1.3 0.1
PFA 20:5 (Eicosapentaenoic)
(g)
0.01 0.0009 0.01 0.0009 0.01 0.0009
PFA 22:6 (Docosahexaenoic)
(g)
0.02 0.005 0.04 ** 0.003 0.05 ** 0.003
Phosphorus (mg) 1523 59 1579 61 1632 59
Potassium (mg) 2683 112 2721 116 2758 110
Protein (g) 76.1 3.3 79.8 3.3 83.1 3.2
Riboflavin (mg) 2.4 0.1 2.5 0.1 2.6 0.1
Selenium (mg) 108 6 116 6 125 6
Sodium (mg) 2862 128 2990 125 3104 121
Thiamin (mg) 1.5 0.1 1.6 0.1 1.6 0.1
Total Choline
(mg) 312 16 378 ** 14 446 ** 10
Total Fat (g) 66.3 3.4 68.9 3.3 71.4 3.3
Total Monounsaturated
Fat
(g)
21.9 1.3 22.9 1.3 23.9 1.3
Total
Polyunsaturaed
Fat (g)
14.7 0.8 15.3 0.8 15.9 0.8
Total Saturated
Fat (g) 23.6 1.4 24.5 1.4 25.3 1.3
Total Sugars (g) 122 6 121 6 121 6
Trans Fat (g) 1.8 0.1 1.8 0.1 1.8 0.1
Vitamin A RAE
(mcg) 766 39 805 35 862 * 36
Vitamin B12
(mcg) 5.7 0.2 5.9 0.2 6.1 0.2
Vitamin B6 (mg) 1.7 0.1 1.8 0.1 1.8 0.1
Vitamin C (mg) 104 13 104 13 104 13
Vitamin D
(D2+D3) (mcg) 8.7 0.5 9.2 0.5 9.8 * 0.5
Vitamin E, as
alpha-tocopherol
(mg)
7.2 0.6 7.4 0.6 7.7 0.6
Vitamin K (mg) 79.3 13.8 79.4 13.8 79.4 13.7
Zinc (mg) 11 0.5 11.3 0.5 11.7 0.5
* 10% higher vs. baseline; ** 20% higher vs. baseline; SE = standard error; PFA = polyunsaturated fatty acids.
Nutrients 2021, 13, 1379 6 of 9
3.3. Nutrient Inadequacy and Adequacy with the Addition of Eggs at Breakfast
When compared to the baseline intakes, the addition of eggs at breakfast resulted
in meaningful outcomes in nutrient inadequacy and nutrient adequacy outcomes. The
percent above the adequate intake for total choline increased from 43.6 and 57.8% with
one and two eggs, respectively, compared to 22.6% at baseline. Similar benefits were
observed for vitamin A and vitamin D, such that the percentage below the estimated
average requirement decreased with the addition of one and two eggs (Table 3).
Table 3. Effects of inclusion of eggs in breakfast on nutrient inadequacy (% below the estimated average requirement) or
nutrient adequacy (% above the adequate intake) among children 1–18-years-old; gender combined; NHANES 2011–2016;
n = 9254.
% of Children Above Adequate Intake or Below Estimated Average Requirement
Nutrients Baseline SE LCL UCL Breakfast + 1
Egg SE LCL UCL Breakfast + 2
Eggs SE LCL UCL
(Scenario 0) (Scenario 1) (Scenario 2)
% Above Adequate
Intake
PFA 18:3
(Octadecatrienoic) (g) 75.6 1.5 72.7 78.6 76.7 1.5 73.8 79.6 77.6 1.5 74.7 80.6
Total Choline (mg) 22.6 0.9 20.9 24.3 43.6 * 1.2 41.4 45.9 57.8 ** 2.8 52.4 63.2
% Below Estimated
Average Requirement
Phosphorus (mg) 13.6 1.1 11.4 15.8 10.8 * 1.1 8.7 12.9 8.3 ** 0.9 6.5 10.1
Protein (g) 0.5 0.2 0.1 0.8 0.3 0.1 0.003 0.5 0.2 0.1 0.0 0.3
Riboflavin (mg) 0.9 0.3 0.3 1.4 0.5 0.2 0.1 0.9 0.3 0.1 0.01 0.6
Vitamin A RAE (mcg) 23.2 1.4 20.6 25.9 18.7 * 1.4 16.1 21.5 14.8 ** 1.2 12.5 17.1
Vitamin D (D2+D3)
(mcg) 92 0.7 90.6 93.4 89.6 * 0.9 88.0 91.3 86.1 ** 0.9 84.2 87.9
* significantly different vs. baseline (Scenario 0); ** significantly different vs. Scenario 1; SE = standard error; PFA = polyunsaturated fatty
acids; LCL = 95% lower confidence level; UCL = 95% upper confidence level.
3.4. Percent of Children above Dietary Guidelines’ Recommended Cutoffs for Daily Saturated Fat
and Sodium
When considering the various dietary models, the differences were less than 10 percent
in comparison with the baseline values for the percent of children above the cutoff of 10%
of caloriesfrom saturated fat in the daily diet. Similarly, differences were below 10 percent
(relative to the baseline) for the percentage above the sodium cutoff of 2300 mg/day, except
when modeling the addition of two eggs at breakfast, wherein the percentage of children
above the sodium cutoff increased by more than 10% versus baseline.
4. Discussion
As breakfast habits in childhood are predictors for eating behaviors in adulthood [20],
establishing healthy breakfast standards in the early years becomes a critical public health
initiative. The current study modeled usual nutrient intakes after various scenarios where
eggs were added to the routine breakfast pattern and the CACFP compliant school breakfast.
The results showed that adding one or two eggs at breakfast in American children
increased several nutrient intakes by greater than 10 to 20 percent in comparison to baseline.
Specifically, modeling the addition of one and two eggs at breakfast, the usual intakes
of total choline, lutein + zeaxanthin, and docosahexanoic acid increased by greater than
20 percent compared to baseline usual intakes. The current analysis also provides evidence
that the addition of eggs at breakfast can play a role in nutrient adequacy and/or inadequacy.
Indeed, the percent above the adequate intake for total choline increased from
43.6 and 57.8% with one and two eggs, respectively, compared to 22.6% at the baseline.
Further, adding eggs to breakfast moderately decreased the percentage of children below
the estimated average requirement.
The recent release of the 2020 Dietary Guidelines Advisory Committee (DGAC 2020)
scientific report included food and nutrition recommendations for birth to 24-month-olds.
Eggs have been recommended as part of the first complimentary foods introduced to infants
Nutrients 2021, 13, 1379 7 of 9
at 4- to 6-months of age (representing a historic first in authoritative food and nutrition
recommendations), and eggs have been recommended as part of a healthy dietary pattern in
older children [9]. The DGAC 2020 also highlighted public health challenges in that several
nutrients are under-consumed by all Americans (1 years-old), including magnesium,
choline, and vitamins A, C, E, and K. However, vitamin D, calcium, dietary fiber, and
potassium have been identified as nutrients of public health concern, implying that the
underconsumption of these nutrients has been associated with adverse health outcomes.
The DGAC 2020 further stated that children aged 9- to 14-years-old have a “constellation of
potential nutritional risk factors that are considered a public health challenge”, with girls
and boys demonstrating inferior intakes of choline, magnesium, and phosphorus [9]. The
current modeling analysis provides evidence to support the addition of eggs within current
breakfast patterns. Indeed, when considering underconsumed nutrients in Americans,
the addition of one and two eggs at breakfast led to increases greater than 10% (relative
to the baseline) in the usual intakes for total choline, vitamin D, and vitamin A—three
nutrients identified by the 2020 DGAC as underconsumed nutrients in all Americans [9].
Furthermore, the current nutrient adequacy analysis showed that the modeling of one and
two eggs at breakfast increased the percentage of children above the AI for total choline.
The DGAC 2020 classified choline as an underconsumed nutrient in particular, as choline
has been extensively documented as a key nutrient in neurodevelopment, metabolism and
physiological functions [21]. Eggs are a leading food source for choline in the diet, such
that one serving (i.e., 50 g, large egg) provides 147 mg of dietary choline [22]. NHANES
data supports the conclusion that the majority of Americans, including children and
adolescents, are not meeting the established recommendations for choline intake, thus
creating a potential public health concern regarding choline intake [23]. A recent review
highlighted the limited data availability on the usual intake of choline in different age
groups and populations, highlighting research on children to address gaps in the scientific
literature [24].
The current analysis has shown that the addition of one and two eggs at breakfast
leads to a greater than usual intake of lutein + zeaxanthin. While a dietary reference intake
has not been established for lutein or zeaxanthin, authoritative guidance recommends
consumption of vegetables (dark green vegetables in particular), as they represent a rich
source of lutein and zeaxanthin. However, dietary guidance has reported low mean intakes
of vegetables across all age groups relative to the recommendations, and children from 1 to
18 years of age all fall below dark green vegetable recommendations in their consumption
habits [8,9]. Eggs are a dietary source for bioavailable lutein and zeaxanthin, with a 50 g
egg contributing approximately 250 g lutein + zeaxanathin [22]. Lutein and zeaxanthin
are carotenoids, with accumulating data supporting a beneficial role in eye health and risk
reductions in terms of the prevalence of ocular diseases [25–27].
As has been documented previously in observational studies similar to the present
analysis, our modeling study has limitations characteristic of epidemiological research.
These limitations have previously been discussed and outlined in numerous publications
[28–30]. Nonetheless, the strengths and robust nature of the NHANES database
provides a valuable insight into American dietary patterns and associated health outcomes.
5. Conclusions
To our knowledge, the current data represent the first study in children that examined
the modeling outcomes following the addition of eggs to breakfast. The addition of one
or two eggs at breakfast in 1- to 18-year-old children increased several positive nutrients,
including total choline, lutein + zeaxanthin, docosahexanoic acid, vitamin D, vitamin A,
and pantothenic acid, by greater than 10 percent in comparison to the usual baseline intakes.
Moreover, the usual intakes of total choline, lutein + zeaxanthin, and docosahexaenoic
acid were elevated by greater than 10 percent relative to the baseline with the addition
of two eggs at breakfast. The current study also showed that adding eggs to breakfast
patterns can play a role in nutrient adequacy where meaningful increases were seen in
Nutrients 2021, 13, 1379 8 of 9
the percentage of children above the established adequate intake for total choline relative
to the baseline. The addition of eggs to breakfast can contribute to nutrient intakes and
overall dietary adequacy and play a role in public health initiatives aimed at increasing the
intake of under-consumed nutrients and nutrients of concern.
Author Contributions: V.L.F.III and Y.P. were responsible for the intellectual conception and interpretation
of the research; V.L.F.III generated the design of the research study and completed the
final analysis; Y.P. drafted the manuscript, and both Y.P. and V.L.F.III provided final editing of the
manuscript. All authors have read and agreed to the published version of the manuscript.
Funding: This research was funded by the Egg Nutrition Center, Rosemont, IL, USA.
Institutional Review Board Statement: The present analysis involves human participants from the
NHANES dataset. The Research Ethics Review Board at the National Center for Health Statistics has
previously approved all procedures for data collection.
Informed Consent Statement: Written informed consent to participate in NHANES was provided
by the participants’ legal guardian/next of kin and has been previously reported by the Centers for
Disease Control and Prevention.
Data Availability Statement: NHANES was used to conduct the present analysis and is a publicaly
available dataset. The NHANES data can be found at https://wwwn.cdc.gov/nchs/nhanes (accessed
on 20 April 2021).
Acknowledgments: The current analysis was supported by the Egg Nutrition Center (ENC).
Conflicts of Interest: ENC had no input into the intellectual conceptualization and design of the
present analysis and overall study; in the gathering, analysis, or data interpretation; in drafting
any version of the manuscript, and in the final decision to publish the study and data. Y.P., as VP
of Nutritional Strategies, collaborates with food, dietary supplements and beverage companies on
various food, nutrition and regulatory affairs projects. Y.P. and V.L.F.III regularly collaborate on
analyses involving the NHANES database. V.L.F.III, as SVP of Nutrition Impact, collaborates with
food, dietary supplement and beverage companies on numerous nutrition research studies, including
publishing study findings involving analyses of the NHANES database.

DOI: https://www.mdpi.com/journal/nutrients