Breastfeeding and Obesity

1
Breastfeeding and Obesity

• Kristen DiFilippo
• FCS 5152

2
US Department of Health and Human Services. The
Surgeon Generals Call to Action to Prevent and
Decrease Overweight and Obesity. Rockville, MD
US Department of Health and Human Services,
Public Health Service, Office of the Surgeon
General 2001.
3
Adult Obesity

• Overweight BMI 25-29.9 kg/m²
• Obese BMI 30 kg/m² or greater

US Department of Health and Human Services. The
Surgeon Generals Call to Action to Prevent and
Decrease Overweight and Obesity. Rockville, MD
US Department of Health and Human Services,
Public Health Service, Office of the Surgeon
General 2001.
4
Childhood Obesity

• Excess adipose tissue
• At risk BMI 85th-95th percentiles
• Obese 95th percentile or above

Policy statement of the American Academy of
Pediatrics Prevention of Pediatric Overweight
and Obesity. Pediatrics. 2003112(2)424-430.
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Children Suffering from Obesity

• 15.3 of 6-11 year olds
• 15.5 of 12-19 year olds
• Higher among minorities and economically
  disadvantaged

Policy statement of the American Academy of
Pediatrics Prevention of Pediatric Overweight
and Obesity. Pediatrics. 2003112(2)424-430.
8
Preschoolers and Obesity
Mei Z, Scanlon KS, Grummer-Strawn LM, Fredman DS,
Yip R, Trowbridge FL. Increasing prevalence of
overweight among US low-income preschool
children The Centers for Disease Control and
Prevention Pediatric Surveillance, 1983-1995.
Pediatrics. 1998101(1). Available at
http//www.pediatrics.org/cgi/content/full/101/1/e
12.
9
Preschoolers and ObesityThe Low Income Group
Mei et al. 2003.
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Statements on Obesity Prevention

• American Academy of Pediatrics
• Prevention is critical
• Treatments are limited
• Need for research of risk factors
• US Department of Health and Human Services
• Need for prevention techniques

Policy statement of the American Academy of
Pediatrics Prevention of Pediatric Overweight
and Obesity. Pediatrics. 2003112(2)424-430.
US Department of Health and Human Services. The
Surgeon Generals Call to Action to Prevent and
Decrease Overweight and Obesity. Rockville, MD
US Department of Health and Human Services,
Public Health Service, Office of the Surgeon
General 2001.
11
Purpose

• The purpose of this research is to examine the
  relationship between breastfeeding and obesity.
• Specifically, factors such as duration of
  breastfeeding, and exclusiveness of breastfeeding
  are studied to determine their correlation to
  obesity.

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Topics

• Relationship between breastfeeding and obesity
• Positive articles
• Inconclusive articles
• Reasons for protective effect of breastfeeding
• Reasons for inconclusive results
• The role of infant formula
• Conclusions

13
Breastfeeding Benefits

• Many positives to breastfeeding
• Species Specific (1,2)
• Protein is adequate, not excessive (5)
• Decreased infant illness (1,2)
• Easily digestible (5)

1. American Academy of Pediatrics. Breastfeeding
and the use of human milk. Pediatrics. 1997
100(6)1035-1039. 2. HHS Blueprint for Action on
Breastfeeding. Washington, D.C. US Department
of Health and Human Services, 2000. 5.
1.                  Position of the American
Dietetic Association Breaking the barriers to
breastfeeding. J Am Diet Assoc. 2001
101(10)1213-1220.
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Breastfeeding and Obesity

• Is obesity prevention a benefit of breastfeeding?
• Studies disagree

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Positive Studies in Developing Countries

• The Hypotheses
• Over-nutrition increases risk of later obesity
• Under-nutrition leads to later obesity
• Optimal infant nutrition (breastfeeding) is
  protective against obesity

Martorell R, Stein AD, Schroeder DG. Early
Nutrition and Later Adiposity. J Nutr.
2001131874S-880S.
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Hypotheses about early childhood nutrition and
later adiposity
Martorell R, Stein AD, Schroeder DG. Early
Nutrition and Later Adiposity. J Nutr.
2001131874S-880S.
17
Actual findings from Martorell et al. Review

• Under-nutrition was not as significant
• Over-nutrition increased risk of later obesity
• Breastfeeding protected against obesity

Martorell R, Stein AD, Schroeder DG. Early
Nutrition and Later Adiposity. J Nutr.
2001131874S-880S.
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Czech Study

• Objective
• Assessing effect of breastfeeding on childhood
  overweight/obesity
• Eastern European socialist society
• Design
• Homogeneous culture
• 5th Nationwide Anthropometrics Survey of Children
  and Adolescents in 1991
• Children 6-14 years

Toshke AM, Viqnerova J, Lhotska L, Osancova K,
Koletzko B, von Kries R. Overweight and obesity
in 6 to 14 year old Czech children in 1991
Protective effect of breast feeding. Journal of
Pediatrics. 2002141(6)764-769.
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Czech Study

• Methods
• Parents questionnaire (97.7 response)
• 5 Categories of Breastfeeding
• Never, lt1 month, 1 to 3 months, 3 to six months,
  gt6 months
• Exclusiveness not differentiated
• Anthropometrics Exam
• Overweight gt90th percentile BMI
• Obese gt97th percentile BMI
• 33,768 children

Toshke AM, Viqnerova J, Lhotska L, Osancova K,
Koletzko B, von Kries R. Overweight and obesity
in 6 to 14 year old Czech children in 1991
Protective effect of breast feeding. Journal of
Pediatrics. 2002141(6)764-769.
20
Czech Study

• Confounding Variables
• Parental BMI (increase)
• Education level of parent (decrease)
• Maternal smoking (increased overweight)
• High birth weight (increase)
• Hours Watching TV (increase)
• Having Siblings
• Physical Activity
• Fruit Consumption

Toshke AM, Viqnerova J, Lhotska L, Osancova K,
Koletzko B, von Kries R. Overweight and obesity
in 6 to 14 year old Czech children in 1991
Protective effect of breast feeding. Journal of
Pediatrics. 2002141(6)764-769.
21
Czech Study Conclusions

• 90.7 of children breastfed
• 3.2 of breastfed children obese
• 4.4 of non-breastfed children obese
• Non-breastfed
• Less siblings, more TV, less likely to eat fruit
• Parents low education, more obese, more mothers
  smoked

Toshke AM, Viqnerova J, Lhotska L, Osancova K,
Koletzko B, von Kries R. Overweight and obesity
in 6 to 14 year old Czech children in 1991
Protective effect of breast feeding. Journal of
Pediatrics. 2002141(6)764-769.
22
Czech Study Conclusions
Toshke AM, Viqnerova J, Lhotska L, Osancova K,
Koletzko B, von Kries R. Overweight and obesity
in 6 to 14 year old Czech children in 1991
Protective effect of breast feeding. Journal of
Pediatrics. 2002141(6)764-769.
23
Czech Study-Other Issues

• Definition of Obese different
• Higher protein content of formula
• Exclusiveness of breastfeeding not defined

Toshke AM, Viqnerova J, Lhotska L, Osancova K,
Koletzko B, von Kries R. Overweight and obesity
in 6 to 14 year old Czech children in 1991
Protective effect of breast feeding. Journal of
Pediatrics. 2002141(6)764-769.
24
Western/Developed Countries

• Many articles
• Adolescents
• 6 year olds
• 5 and 6 year olds

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Adolescents (Gillman et al. 2001)

• Survey of 9-14 year olds in Growing Up Today
  Study (Mothers in Nurses Healthy Study II)
• 8186 girls and 7155 boys
• Overweight-BMI above 95th percentile

Gillman MW, Rifas-Shiman SL, Camargo CA Jr,
Berkley CS, Frazier AL, Rockett HR, Field AE,
Colditz GA. Risk of overweight among adolescents
who were breastfed as infants. JAMA.
2001285(19)2461-2467.
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Duration of Breastfeeding
Adapted from Gillman MW et al. 2001
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Conclusions of Gillman et al 2001

• Infants fed more breast milk than formula are
  less likely to be overweight at ages 9-14
• Infants breastfed for longer duration are less
  likely to be overweight at ages 9-14

Gillman MW et al. 2001
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6 year olds (Bergmann et al. 2003)

• Longitudinal birth cohort study
• Effects of breastfeeding more than two months on
  weight at 6 years
• Overweight- BMI 90th percentile
• Obese- BMI 97th percentile
• 1314 children from 6 delivery units
• 918 could be followed until age 6
• 480 cases with complete data

Bergmann KE, Bergmann RL, von Kries R, Bohm O,
Richter R, Dudenhausen JW, Wahn U. Early
Determinants of childhood overweight and
adiposity in a birth cohort study role of
breast-feeding. Int J Obes Relat Metab Disord.
200327(2)162-172.
29
Study Groups(Bergmann et al. 2003)

• Breastfed Group
• Breastfed 3 months or more

• Bottle Fed Group
• Bottle fed from birth
• Or
• Breastfed less than 3 months

Bergmann et al. 2003
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Conclusions Bergmann et al. 2003

• By 3 months
• Higher average BMI for Bottle Fed
• From 6 months on
• Higher proportion of children had BMI above 90th
  and 97th percentiles in the Bottle Fed Group
• From 4 years to 5 years to 6 years
• Prevalence of obesity doubled, then tripled in
  Bottle Fed Group
• Only minor changes in obesity prevalence in
  Breastfed Group

Bergmann et al. 2003
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Breast feeding and obesity cross sectional
study. von Kries et al. 1999

• Looking for a simple obesity prevention strategy
  with out potential side effects
• Large population
• Follow-up on Kramer 1981
• Canadian cross-sectional study for 1320
  adolescents born in the 1960s
• Low breastfeeding rates in Canada in 1960s
• Industrialized countries have changed

von Kries R, Koletzko B, Sauerwald T, von Mutius
E, Barnert D, Grunert V, von Voss H. Breast
feeding and obesity cross sectional study. BMJ.
1999319147-150.
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Subjects

• Members of obligatory health exam for school
  entry
• Bavaria, Southern Germany
• 134,577 children evaluated in health exam
• 13,345 children included in study
• German Children between ages 5 and 6

von Kries R, Koletzko B, Sauerwald T, von Mutius
E, Barnert D, Grunert V, von Voss H. Breast
feeding and obesity cross sectional study. BMJ.
1999319147-150.
33
Methods-2 Parts

• School Entry Exam
• Parent Questionnaire

von Kries R, Koletzko B, Sauerwald T, von Mutius
E, Barnert D, Grunert V, von Voss H. Breast
feeding and obesity cross sectional study. BMJ.
1999319147-150.
34
Methods-Exam

• Height and Weight measured during exam
• BMI calculated
• Overweight- BMI 90th percentile
• Obese- BMI 97th percentile
• Percentiles from ALL children entering Bavarian
  schools

von Kries R, Koletzko B, Sauerwald T, von Mutius
E, Barnert D, Grunert V, von Voss H. Breast
feeding and obesity cross sectional study. BMJ.
1999319147-150.
35
Methods-Questionnaire

• Was your child breastfed?
• For how long was your child exclusively
  breastfed?
• 2 months or less
• 3 to 5 months
• 6 to 12 months
• More than a year
• Other questions for confounding variables

von Kries R, Koletzko B, Sauerwald T, von Mutius
E, Barnert D, Grunert V, von Voss H. Breast
feeding and obesity cross sectional study. BMJ.
1999319147-150.
36
Confounding Variables
von Kries R, Koletzko B, Sauerwald T, von Mutius
E, Barnert D, Grunert V, von Voss H. Breast
feeding and obesity cross sectional study. BMJ.
1999319147-150.
37
Results
von Kries R, Koletzko B, Sauerwald T, von Mutius
E, Barnert D, Grunert V, von Voss H. Breast
feeding and obesity cross sectional study. BMJ.
1999319147-150.
38
Prevalence of Overweight and Obesity for 5 and 6
year olds in Rural Bavaria
Adapted from Von Kries et al. 1999
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Discussion

• Largest Epidemiological Study
• A great reason to encourage breastfeeding

von Kries R, Koletzko B, Sauerwald T, von Mutius
E, Barnert D, Grunert V, von Voss H. Breast
feeding and obesity cross sectional study. BMJ.
1999319147-150.
40
Inconclusive Articles

• Developing Countries
• Brazil
• Western/Developed Countries
• Children of the British Cohort
• 3-5 year old US children

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Brazil Study (Victora et al. 2003)

• Objective
• Association between duration of breastfeeding and
  adolescent adiposity
• Pelotas, Brazil
• Participants
• All newborn infants in city hospitals in 1982
• 78 of males located at 18 when enrolling in army

Victora CG, Barros F, Lima RC, Horta BL, Wells J.
Anthropometry and body composition of 18 year
old men according to duration of breast feeding
Birth cohort study from Brazil. BMJ.
2003327(7420)901.
42
Methods, Victora et al. 2003

• At birth, 1982
• Infant examination
• Mothers interviewed
• Early 1983
• Children born January-April 1982 sought at home
• 1984 and 1986
• All city households visited
• 87 and 84 of original cohort located

Victora CG, Barros F, Lima RC, Horta BL, Wells J.
Anthropometry and body composition of 18 year
old men according to duration of breast feeding
Birth cohort study from Brazil. BMJ.
2003327(7420)901.
43
Methods, Victora et al. 2003

• 2000
• Men joined army
• Anthropometrics measured

Victora CG, Barros F, Lima RC, Horta BL, Wells J.
Anthropometry and body composition of 18 year
old men according to duration of breast feeding
Birth cohort study from Brazil. BMJ.
2003327(7420)901.
44
2000 Measures

• Standing and Sitting Height
• Leg Length
• Weight
• Subscapular and Tricepts Skinfolds
• Fat and Fat-free Mass

Victora CG, Barros F, Lima RC, Horta BL, Wells J.
Anthropometry and body composition of 18 year
old men according to duration of breast feeding
Birth cohort study from Brazil. BMJ.
2003327(7420)901.
45
Overweight and Obesity

• First Definition
• Overweight- BMI gt85th percentile
• Obese-BMI gt85th percentile and skinfolds above
  90th percentile

• Second Definition
• Overweight- BMI gt25
• Obese- BMI gt30

Victora CG, Barros F, Lima RC, Horta BL, Wells J.
Anthropometry and body composition of 18 year
old men according to duration of breast feeding
Birth cohort study from Brazil. BMJ.
2003327(7420)901.
46
Brazil Study Limitations

• 8.4 of Mothers reported no breastfeeding
• 14.9 of Mothers reported breastfeeding 1-29 days
• Misclassification
• Two Groups Merged
• Exclusive Breastfeeding Rare
• No females

Victora CG, Barros F, Lima RC, Horta BL, Wells J.
Anthropometry and body composition of 18 year
old men according to duration of breast feeding
Birth cohort study from Brazil. BMJ.
2003327(7420)901.
47
Brazil Study Advantages

• Prospective Study
• Assesses Several Measures of Adiposity

Victora CG, Barros F, Lima RC, Horta BL, Wells J.
Anthropometry and body composition of 18 year
old men according to duration of breast feeding
Birth cohort study from Brazil. BMJ.
2003327(7420)901.
48
Confounding Variables

• 1982
• Monthly Family Income
• Maternal Education
• Pre-pregnancy BMI
• Maternal Smoking
• Birth weight
• Gestational Age

• 2000
• Skin Color (white/other)
• Physical Activity
• Type of Diet
• Daily Smoking
• Alcohol intake

Victora CG, Barros F, Lima RC, Horta BL, Wells J.
Anthropometry and body composition of 18 year
old men according to duration of breast feeding
Birth cohort study from Brazil. BMJ.
2003327(7420)901.
49
Prevalence of Obesity
Adapted From Victora CG, Barros F, Lima RC,
Horta BL, Wells J. Anthropometry and body
composition of 18 year old men according to
duration of breast feeding Birth cohort study
from Brazil. BMJ. 2003327(7420)901.
50
BMI For Breastfeeding Duration
Adapted From Victora CG, Barros F, Lima RC,
Horta BL, Wells J. Anthropometry and body
composition of 18 year old men according to
duration of breast feeding Birth cohort study
from Brazil. BMJ. 2003327(7420)901.
51
Children of British Cohort

• 2631 Children
• Obesity- BMI gt95th Percentile
• Confounding Factors
• Conclusions
• Mean BMI and Obesity Lower in Group Breastfed for
  2-3 Months
• This Number was not significant

Li L, Parsons TJ, Power C. Breast feeding and
obesity in childhood cross sectionals study.
BMJ. 2003327904-905.
52
3-5 Year Old US Children

• Objective-Determine association between
  Breastfeeding and Breastfeeding duration and Risk
  of Young Children being Overweight
• Data from NHANES III
• 2685 US 3-5 year olds
• At Risk for Overweight- BMI 85th-95th percentile
• Overweight- BMI gt95th percentile

Hediger ML, Overpeck, MD, Kuczmarski, RJ, Ruan
WJ. Association Between Infant Breastfeeding and
Overweight in Young Children. JAMA.
2001285(19)2453-2460.
53
Conclusions

• Reduced Risk for Overweight for Ever Breastfed
  Compared to Never Breastfed
• No Reduction in actually being overweight
• Breastfeeding less significant

Hediger ML, Overpeck, MD, Kuczmarski, RJ, Ruan
WJ. Association Between Infant Breastfeeding and
Overweight in Young Children. JAMA.
2001285(19)2453-2460.
54
Reasons for Protective Effect

• Early Growth from increase in fat cell size, not
  number (7)
• Maternal Control Decreased in Breastfeeding (22)
• Higher insulin levels in bottle fed children (9)
• Energy metabolized and Protein intake lower in
  breastfed infants (9)

7. Martorell et al. 2001, 22. Fisher et al.
2000, 9. von Kries et al. 1999
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Reasons for Protective Effect

• Protein is adequate, not excessive (5,8,27)
• Lower Energy Density in Human Milk (8,27)

5. Position of the American Dietetic Association
Breaking the barriers to breastfeeding. J Am
Diet Assoc. 2001 101(10)1213-1220. 8.
Agostoni C. Breast Feeding and Childhood
Obesity. BMJ. 1999319147-150. 27. Toshke et
al. 2002
56
Reasons for Inconclusive/Mixed Results

• Observational Studies (6)
• Different Methods (6)
• Ethics (6)
• Retrospective Studies (6)

6. Clifford et al. 2003
57
Reasons for Inconclusive/Mixed Results

• Exclusive/Nonexclusive Breastfeeding (6,7)
• Confounding Variables (6,7)
• Age of obesity measurement varies (6)
• Definition of Overweight and Obesity varies (7)

6. Clifford et al. 2003, 7. Martorell et al.
2001.
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A Word on Formula

• Formulas improving
• New Goals of Formula
• Mimic outcome of breastfed infant
• (not match composition of breast milk)
• Long-chain polyunsaturated fatty acids
• Prebiotics and probiotics
• Nucleotides
• Protein quantity

Agostoni C, Haschke F. Infant formulas. Recent
developments and new issues. Minerva Pediatr.
200355(3)181-194.
59
The Role of Formula

• Universal Breastfeeding Not Recommended
• Drug use
• Tuberculosis
• HIV
• Prescribed Medications
• Breast feeding is not always an option

Health People 2010. Washington DC US
Department of Health and Human Services, 2000.
Available at http//www.health.gov/healthy
people.
60
Overview

• Mixed Results
• Some show relationship between obesity and
  breastfeeding
• Some show now effect of breastfeeding
• Causes of Positive Effect
• Reasons for Mixed Results

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Conclusions

• The relationship between Obesity and
  Breastfeeding is unclear
• No known negative effects of breastfeeding on
  obesity
• The effect of breastfeeding is not as strong as
  other contributors to obesity

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Professional Uses

• In most cases breast milk is best
• Recommendations are to breastfeed exclusively for
  6 months, and with complementary foods for at
  least 12 months (5)
• Epidemic of overweight in children and adults
• Breastfeeding may help
• Many other reasons for breastfeeding

5. Position of the American Dietetic Association
Breaking the barriers to breastfeeding. J Am
Diet Assoc. 2001 101(10)1213-1220.
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Questions

• ???