Breakfast skipping and exercising before breakfast- association with patterned hair loss

INTRODUCTION

Patterned hair loss (PHL), a common condition affecting both men and women, is a type of non-cicatricial alopecia characterized by gradual replacement of terminal hairs on the frontal and the vertex region of the scalp with thin vellus follicles that do not reach the full length and lead progressively to a visible reduction in hair density.^[1]

Over the past few years, numerous studies have been published showing a relationship between hormones, genetics, inflammation, oxidative stress, micronutrients, and patterned hair loss.^[2-4] Studies on amino acids like histidine, cysteine, vitamins belonging to the B complex like B1, B6, B12, Biotin, folic acid, vitamin C, vitamin E, copper, zinc, have been documented in the role in the treatment of androgenetic alopecia.^[5,6] However, no study has so far suggested any role between skipping breakfast, exercising on an empty stomach, and PHL.

MATERIAL AND METHODS

A cross-sectional study was carried out at a private center located in Mumbai, India. A total of 41 patients, from July 2024 to June 2025, who complained of hair loss were dermoscopically analyzed using DermLite Pro and Heine to see the diameter variability of >20% and recruited in the study [Figure 1].

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Figure 1: Dermoscopy showing 20% hair diameter variability. (DermLite II Pro dermatoscope, contact, x10).

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A detailed history was obtained, including age, hair loss, duration of volume loss, approximate number of hair strands lost in a day, history of baldness in parents and grandparents. Time of waking up and the first meal with its contents were all noted. Unhealthy breakfast practices were observed in the participants; healthy being described as the first meal of the day eaten before the start of daily activities (errands, travel, work, exercise); within 2 hours of waking, and a caloric value between 20-35% of the daily energy needs and consuming >50 kcal.^[7,8]

Exercise schedules, meals before exercise, and the type of exercises were recorded. The metabolic equivalent (MET) hours before the first meal were calculated in those following unhealthy breakfast practices. MET is the ratio of the person’s working metabolic rate to the resting metabolic rate. One MET is defined as the energy cost of sitting quietly and is equivalent to a caloric consumption of 1kcal/kg/hour. Table 1 was used to calculate MET in hours for the participants.^[9] Drugs taken by the patients and other diseases afflicting the patients were documented.

RESULTS

Data is summarized in Table 2.

Unhealthy breakfast practice: Participants taking breakfast after 2 hours of waking up, engaging in rigorous physical activity before a meal, or having a light meal like a cup of tea/green tea/hot water with lemon and honey (<50 kcal) at least 10 days a month were labelled as following unhealthy breakfast practices. It was found that 35(85.36%) participants were categorized in this group, out of which five participants had their first proper meal within 2 hours of waking up, but engaged in moderate to vigorous physical activities before their breakfast. Based on the operational definition used in this study, they have been classified as following unhealthy breakfast practices.

Exercise- physical recreational activity- 20 (48.8%) of the participants engaged in physical recreational activities (other than their daily chores) before the hair loss started for a mean duration of 1.56 years, with the data being distributed normally, as shown in Graph 1 with the superimposed bell-shaped curve. The exercises mentioned by the participants included mild to moderate ones like slow or brisk walking, postural yoga, swimming; heavy workouts included running, skipping, weight training, aerobics, and dancing. It should be noted that people often switch from mild to moderate to heavy exercises in between. Also, some were regular (at least five days a week), whereas others were irregular in their attendance.

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Graph 1: The following histogram is plotted with the actual counts, and an ideal bell-shaped curve is superimposed on it for reference.

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Two (10%) participants in the above did exercises in the afternoon to late evening, whereas the others did them in the morning before the first meal.

Metabolic equivalent- Only in the 35 patients following unhealthy breakfast practices as mentioned above, the MET from the time of waking to the time of having the first meal was calculated, beginning from the onset of the unhealthy breakfast practice in their lives to the onset of hair/volume loss. Since patterned hair loss does not develop in a single day but rather evolves over months to years, the calculation of MET in fluctuating, non-static dietary behavior and the exercise patterns preceding the onset in such retrospective designs would necessarily be approximate.

Co-morbidities and drugs: Two female patients had polycystic ovarian disease (PCOD), one patient was on an antihypertensive, and four patients had diabetes.

DISCUSSION

Breakfast is the most important meal of the day and a marker of a healthy lifestyle. We aimed to find the relation between the first meal of the day and patterned hair loss.

There is no universally accepted definition of breakfast skipping in the literature. The current study adopts the definition of Timlin and Pereira in their work on linking obesity with breakfast skipping, which has been implemented in other regional studies, too.^[10] Additionally, Adam Drewnowski also proposed the threshold of > 50 Kcal that is implemented in the current study.^[11]

We also included exercise before breakfast and termed them as unhealthy breakfast practice as all three, namely, first meal less than 50 kcal, or beyond 2 hours, and exercising before this meal leads to deterred fasting physiology ending in early- day energy deprivation. It has to be noted that most of the references used describe breakfast skipping as the first meal of the day, not taken within 2 hours of waking up.

In 41 participants with patterned hair loss, 35 participants followed an unhealthy breakfast practice in terms of consumption of the first meal of the day. Out of the 35 participants, 30(73.17%) delayed the first meal beyond 2 hours. In a study carried out by Sivaramakrishnan and Kamath, it was seen that in Mumbai, 16 % of children, adolescent and teens completely skip their meals (the definition of the first meal in the study was before 9 am for morning school goers).^[7] 2 other studies done in Delhi and Aligarh found that 30% and 33.8% of school-going students skipped their breakfast, respectively.^[12,13] Another study from Coimbatore had 18.8 % college goers with irregular breakfast habits.^[14] Thus, this study has a higher percentage of people consuming the first meal after 2 hours of waking.

In this study, 20 (48.8%) people engage in exercises in their daily schedule. On average, the participants observed the onset of hair loss approximately one and a half years after initiating what they perceived to be a healthier lifestyle that included regular exercise. This proportion appears higher when compared to findings from the Indian Council of Medical Research-India Diabetes study (ICMR-INDIAB study), Phase-1, which reported that fewer than 10% of urban and rural Indians engaged in recreational physical activity.^[15]

Although there are no regional studies to assess the trend in terms of the time during the day, a study by Mota et al. found that moderate to vigorous physical activities done by school kids did not significantly differ in their pattern, although boys (53.8) preferred late afternoon to evening time as compared to early to mid-morning.^[16] In this study, the prevalence of people exercising before the first meal in the morning was 90%, which is significantly higher.

Variations in the frequency of the consumption of delaying breakfast beyond 2 hours of waking and the exercising schedule were found to further complicate the study design. But the MET-hours calculated from the time of waking to the first meal solved the above issue by being independent of the frequency factor. Here, it is noticed that patients with a strong genetic history of androgenic alopecia seen in both maternal and paternal sides started seeing hair loss after MET of 3630 was reached, in comparison with the average of other participants being 10123, which can be interpreted as the early occurrence of patterned hair loss in patients with a strong genetic history following unhealthy breakfast practices.

Glycogen stores are significantly depleted following long overnight fasting. A good breakfast increases the glycemic load and glycemic index, whereas the blood sugar levels in breakfast skippers and people exercising after prolonged fasting decrease to a level putting the body in a state of stress. Stress was linked with increased cortisol levels in breakfast skippers, while regular consumption of cereal-based breakfast was linked with reduced cortisol levels.^[8]

This study showed a higher prevalence of unhealthy breakfast practices in PHL, both of which tend the body towards hypoglycemia. In the same way, prolonged exercise can also result in hypoglycemia without affecting the patient's endurance (fatigability).^[17] Increased levels of testosterone have been reported during strenuous exercise, with contrasting observations of lower end of normal ranges of testosterone during long-term endurance training exercise. The authors have attributed this as body’s response to low sugar levels.^[18]

Studies by Narad et al., Duskova et al, and Starka et al. have shown that there is an interplay between testosterone, dehydroepiandrosterone sulfate, and balding.^[19-21] These molecules have also been associated with blood glucose levels in parallel studies conducted by different authors, like Haffner et al., who showed in their study that free testosterone and dehydroepiandrosterone sulfate were inversely associated with glucose concentrations.^[22] It has been implied that testosterone increases with decreased blood glucose concentration, such as in situations like prolonged fasting and prolonged exercise.^[22] We thus see that there is an interplay in the triad consisting of hormones, blood glucose, and PHL, and therefore dietary habits that tend to lower blood glucose, like exercising on an empty stomach and delaying the first meal, can logically affect patterned hair loss.

LIMITATIONS

The sample size is small, as this is a preliminary explorative pilot study, and no prior power calculation was done. The non-static lifestyle patterns of breakfast and exercise fluctuate from day to day and across months and years, and hence, recall bias is unavoidable.

CONCLUSION

People skip breakfast due to several reasons, like lack of time, not feeling hungry in the morning, or as a means to lose weight quickly. Many studies have been published relating breakfast skipping to increased chances of obesity, cardiovascular complications, increased stress, diabetes, etc., but no study so far has associated it with PHL. Additionally, no study has been published so far attributing a relatively healthy habit like exercise to patterned hair loss. This is the first study of its kind relating the body’s physiological response to lowering blood glucose by unhealthy breakfast practices to hair loss and offers a wide scope of research in this area.