Breastfeeding Seminar Anderson

7/28/2019 Breastfeeding Seminar Anderson

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Impact of Infant Feeding on

Postpartum Body Composition

Alex Kojo Anderson, PhD, MPH, CPH

Dept. of Foods and NutritionThe University of Georgia



Outline

• Overweight/Obesity situation

• Effect of overweight/obesity

• Relation between infant feeding andoverweight/obesity

• Research findings

• Conclusions



Obesity

• Defined as an excessive deposition of

body fat resulting from an imbalance

between food intake and energy

expenditure

• Cause is multi-factorial

– Genetic predisposition

– Cultural beliefs and personal behaviors

– Environmental influences of food intake and

physical inactivity



Assessment of

Overweight/Obesity• Body Mass Index (BMI) used as an initial

assessment method

• For adults

– Underweight: BMI < 18.5 kg/m2

– Normal weight: BMI = 18.5-24.9 kg/m2

– Overweight: BMI = 25.0-29.9 kg/m2

– Obese: BMI > 30.0 kg/m2

• For children

– Age and gender-specific CDC/WHO BMI growth

charts used



Definition of Overweight

• Overweight: ≥ 85th

but < 95th

BMI percentile for age and gender

• Obesity: ≥95th BMI percentile for age and gender

• For adiposity, body composition testing should

be used to confirm presence of excessive body

fat – Underwater weighing (UWW)

– Dual X-ray Absorptiometry (DXA)

– Skin-fold measurement

– Deuterium dilution

– Bioelectrical impedance

– BOD POD or PEA POD



BMI and Body Fat

High Body Fat by BMI-for-Age Category Girls,

8 –19Years, 1999 –2004



Trends in Obesity Among U.S.

Children and Adolescents



Prevalence of ObesityChildren and

Teens, 6 –19 Years, 1999 –2008



Prevalence of Severe Obesity

Children and Teens, 6 –19 Years,

1999 –2008



Morbidity Associated with

Overweight/Obesity• Endocrinologic

– Hyperinsulinemia

– Insulin resistance

– Early puberty – Polycystic ovary

syndrome

– dysmenorrhea

• Cardiovascular

– Dyslipidemia

– Hypertension

– Metabolic syndrome

• Orthopedic

– More pronounced

among children with

early onset of overweight



• Respiratory Disorders

– Hypoventilation

syndrome

– Sleep apnea – Asthma (BMI > 85th

percentile)

• Hyperinsulinemia – Slight increase in

prevalence at 85-90th BMI

percentiles

– Dramatic increase in riskabove 97th BMI percentile

– Impaired glucose tolerance

• Non-Insulin

Dependent Diabetes(Type 2)

Medical Complications Associated

with Overweight/Obesity



Annual Medical Cost of

Obesity



Postpartum Obesity

• 2005-2006:

– 34% of adults are obese (BMI ≥30 kg/m2)

– Over 43% women gain above the ideal recs for

weight gain during pregnancy – About 44% are overweight pre-pregnancy

Ogden, et al. National Center for Health Statistics, 2007.

Pregnancy Nutrition Surveillance System, Center for Disease Control and Prevention, 2006.



Pediatric Obesity

• 1999-2010: percentage of overweight (≥95th

percentile)

– 15.5% of adolescents (12 –19 y.o.)

– 15.3% of school-age children (6 –11 y.o.)

– 13.2% of pre-school children (2-5 y.o.)

• 1988-1994: percentage of infants above 95th percentile

(6-11 months old)

– Boys: 7.5%

– Girls: 10.8%

Ogden, et al. Jour of the Amer Med Assoc , 2002;288:1728-1732.

Ogden, et al. Pediatrics, 1997;99.



Obesity in the United States

2007 –2008 • Children and teens

(2 –19 years)

– 16.9% obese: ~12.5

million• Adults (≥20 years)

– 33.8% obese: ~ 73

million



What is the Weight of the

Nation? • Average American

adult is more than

24 pounds heavier

today than in 1960• 23.5 million (10.7% )

of adults have

diabetes

• About 55% of adults

with diagnosed

diabetes are obese www.cdc.gov/nchs/data/ad/ad347.pdf

www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf www.cdc.gov/mmwr/preview/mmwrhtml/mm5345a2.htm



Prenatal/Pregnancy TargetsThe Number of Baby Friendly Steps in Place Predicts

Early Breastfeeding Cessation



Is breastfeeding associated with

lower rates of overweight?

• Evidence for a relationship between

breastfeeding and obesity but results are

inconsistent

– Protective (Victora et al., 2003; Li et al., 2003; Arenz et al., 2004; Harder et al., 2005;

Scholtens et al., 2008)

– Increase risk (Agras et al., 1990;Kramer et al., 2008)

– No association (Wadsworth et al., 1999; O’Callaghan et al., 1997; Zive et al., 1992)



The Relationship between Infant Feeding

and Maternal Weight Loss

• Women who continue to EBF lose more

weight at 4-6 months postpartum

compared to those who begin solids at 4

months

• Many studies regarding BF and maternal

weight/fat loss are inconclusive

Dewey, et al. Jour of Nutr , 2001;131:262-267.

Gunderson & Abrams. Epi Rev, 1999;21:261-275.



The Relationship between Infant Feeding

and Childhood Overweight

• Breastfeeding is protective against

childhood overweight later in life

– Dose-dependent

– Infants fed infant formula during the 1st week

of life = ↑ risk obesity later

Owen, et al. Pediatrics, 2005;115:1367-1377.

Harder, et al. Amer Jour of Epi , 2005;162:397-403.

Stettler, Stallings, & Troxel. Circulation, 2005;111:1897-1903.



Potential Explanation/Mechanism

in the Mother

• Energy cost of breast milk production – Milk production requires about 500 kcal/day

based on an average milk secretion of 750 –

800 ml – About 500 kcal above pre-pregnancy daily

energy requirement

Rodwell Williams & Schlenker, 2003

Insel et al., 2002

Hills-Bonczyk et al., 1993



Potential Explanation/Mechanism in

the Infant

• Learned self-regulation of energy intake

– Breastfeeding allows infant to control intake

based on internal satiety cues

– Bottle-fed infants may be encouraged to finish

bottle even if they are full

– This may lead to later differences in ability to

self-regulate energy intake



Effects of Over Feeding in Early Life

• Animal studies

– Overfeeding in infancy leads to increase

number and size of fat cells• Human studies

– Rapid weight gain during infancy is

correlated with childhood obesity (Ong et al., 2000;

Stettler et al., 2002)



Infant Feeding and Infant Body

Composition

• BF infants have lower FFM and higher FM

• MF/FF infants tend to weigh more than BF

infants

Butte, et al. Pediatrics, 2000;106:1355-1366.

Ong, et al. Pediatrics, 2006;117:e503-508.



• Breastfeeding is associated with:

– Lower weight for height & lower rates of

Type II diabetes (AOR = 0.64) in Pima

Indians 10-39 yrs of age (Pettitt et al., 1997)

– Lower risk of Type II diabetes (AOR =

0.24) in Native Canadian children

[breastfed ≥ 12 mo] (Young et al., 2002)

– Lower fasting insulin and post-challengeglucose levels in Dutch adults 48-53 yrs(Ravelli et al., 2000)



Early Protein Intake and

Subsequent Body Fatness

• Formula-fed infants consume 66-70%

more protein than breastfed infants at 3-6

mo; by 12 mo, intakes may be 5-6 times

the requirement

• High protein intake stimulates higher

insulin secretion leading to adipose tissue

deposition



Breastfeeding & Obesity

• Duration: 4% reduction of odds of

overweight per additional month of

breastfeeding (31% reduction for 9

months vs. never breastfed) (Harder et al., 2005)

• Exclusivity: Reduction in risk is greater

among studies looking at exclusive

breastfeeding (24%) than among partial

breastfeeding studies (13%) (Owen et al., 2005)



Current Research Findings

from my Lab• Evaluating the impact of infant feeding on

maternal and infant body composition



Longitudinal Study

• Inclusion Criteria

– Pregnant women 18 years or older

– In their third trimester

– Free of pregnancy complications

– Not on any medication that may

affect weight and body composition

– Non-smoker

• Second screening after delivery



Methods

• 2-groups of participants – Exclusive Breastfeeding

– Mixed Feeding

• Interviews at each visit

• Body composition measurement @:

– 36 wks gestation, 2, 4, 8, and 12 wks

postpartum for mother

– 2, 4, 8, and 12 wks postpartum for infant



Body Composition Measurement:

Mothers

• Anthropometric measurements: – Weight (BOD POD)

– Height (Seca 214 portable stadiometer)

• BOD POD: – Air displacement plethysmography

– Results given include:• % fat

• % lean

• Estimated RMR

• Fat weight

• Lean weight

• Total weight



BOD POD

Image from www.BODPOD.com



Body Composition Measurement: Infants

• Anthropometric measurements:

– Weight (PEA POD)

– Recumbent length (Seca 416 mechanical

infantometer)

• PEA POD:

– Air displacement plethysmography



Participant Characteristics According to Infant

Feeding PracticeExclusive Breastfeeding Mixed Feeding

Age (yrs) 30.5 ± 5.7 29.0 ± 4.4

Years of formal education 17.5 ± 2.3 17.0 ± 2.9

Gestational age at delivery (wks) 39.5 ± 0.9 39.2 ± 1.0

Prepregnancy weight (kg) 62.9 ± 10.2 67.2 ± 12.5

Maternal height (cm) 164.7 ± 6.7 160.9 ± 5.7

Prepregnancy BMI (kg/m2) 23.2 ± 4.2 25.4 ± 5.1

Maternal weight at 36 weeks gestation

(kg)

74.8 ± 10.0 81.6 ± 10.6

Maternal weight at delivery (kg) 75.9 ± 10.2 82.9 ± 10.7

Pregnancy weight gain (kg) 15.1 ± 4.0 15.4 ± 4.5

Infant birthweight (kg) 3.4 ± 0.4 3.5 ± 0.5

Infant birth length (cm) 51.3 ± 1.9 50.9 ± 2.3

Anderson et al., Infant, Child and Adolescent Nutrition (ICAN): submitted



Anderson AK; International Journal of Pediatrics; in press



Maternal and infant characteristics by infant gender

Female (n=18) Male (n=22)

Maternal data

Age (yr) 30.4±5.2 29.6±5.0

Height (m) 1.6±0.1 1.6±0.1

Pre-pregnancy weight (kg) 66.2±13.2 61.1±8.5

Pre-pregnancy body mass index (kg/m2) 24.7±5.9 22.7±2.8

Maternal weight at 36 weeks gestation (kg) 77.1±12.5 75.8±8.3

Maternal weight at delivery (kg) 78.5±12.6 76.9±8.9

Pregnancy weight gain (kg) 14.9±3.9 15.4±4.3

Gestational age at delivery (wks) 39.4±0.8 39.4±0.9

Years of education 17.2±2.6 17.6±2.6

Parity

Primiparous

Multiparous

7 (38.9)

11 (61.1)

9 (40.9)

13 (59.1)

Marital status

Single

Married

2 (11.1)

16 (88.9)

2 (9.1)

20 (90.9)

Race/Ethnicity

White

Black

15 (83.3)

3 (16.7)

19 (86.4)

3 (13.6)

Infant data

Birthweight (kg) 3.4±0.5 3.6±0.4

Birth length (cm) 50.6±1.7 52.0±2.2




Participant characteristics and their associations with

gestational weight gainn (%) Gestational weight gain (kg)

(mean ± SD)

Age of Participant

< 25 years

≥ 25 years

5 (12.5)

35 (87.5)

13.4 ± 2.8

15.4 ± 4.2

Education

College graduate

More than College

16 (40.0)

24 (60.0)

16.4 ± 4.6

14.3 ± 3.5

Race/ethnicity*

White

Black

35 (87.5)

5 (12.5)

15.7 ± 4.0

11.8 ± 3.1

Marital Status Married

Single

36 (90.0)

4 (10.0)

15.4 ± 4.2

12.9 ± 1.3

Employment Status

Full-time

Part-time

Unemployed

23 (57.5)

12 (30.0)

5 (12.5)

15.7 ± 3.8

13.9 ± 4.8

15.4 ± 3.9

Delivery Type

Vaginal

Caesarean section

31 (77.5)

9 (22.5)

15.5 ± 4.3

13.8 ± 3.2

Parity

Primiparous

Multiparous

13 (32.5)

27 (67.5)

16.5 ± 3.9

14.5 ± 4.1

Prepregnancy BMI (kg/m2)

< 19.8

19.8-26.0

26.0-29.0

≥ 29.0

3 (7.5)

27 (67.5)

6 (15.0)

4 (10.0)

12.4 ± 1.1

15.9 ± 4.1

15.6 ± 4.4

11.8 ± 2.8




Proportion of mothers who gained insufficient,

recommended and excessive weight during pregnancy

by pre-pregnancy BMI*

Pre-pregnancy BMI

Pregnancy Weight Gain

Insufficient weight gain

(%)

Recommended weight

gain (%)

Excessive weight gain

(%)

<19.8 kg/m2 (n=3) 33.3 66.7 0.0

19.8 – 26.0 kg/m2 (n=27) 3.7 55.6 40.7

26.0 – 29.0 kg/m2 (n=6) 0.0 16.7 83.3

>29.0 kg/m2 (n=4) 0.0 0.0 100.0

*The percentage of mothers who gained insufficient, recommended and excessive weight gain during

pregnancy by pre-pregnancy BMI category differed between categories (x 2 = 14.6, p<0.024).




Maternal Weight on

Breastfeeding Success• Older women (> 25 yrs) and normal BMI EBF

through the first 12 weeks

– Older women with previous experience

– Hormonal differences b/n normal weight andoverweight/obese women (Rasmussen & Kjolhede, 2004; Hilson et al., 2006)

– Overweight/obese women tend to have lower

prolactin levels during the early postpartum period(Rasmussen & Kjolhede, 2004; Hilson et al., 2006)

– Delayed lactogenesis II because of dependence onprolactin (Rasmussen & Kjolhede, 2004; Hilson et al., 2006)



0

2

4

6

8

2 wks 4 wks 8 wks 12 wks

Duration

W e i g h t c h a n g e ( k g )

Exclusive breastfeeding Mixed Feeding

-12

-10

-8

-6-4

-2

0


Duration

W e i g h t C h a

n g

( k g )

Exclusive breastfeeding Mixed Feeding

Maternal postpartum weight

change with respect toprepregnancy weight

Maternal postpartum weight

loss with respect to weight at

delivery

Hatsu et al., International Breastfeeding Journal , 2008



Pattern of postpartum maternal weight

loss by feeding group

0

1

2

3

4

5

6

4 weeks 8 weeks 12 weeks

Time

W e i g h t c

h a n g e i n k g

EBF

MF

The differences in postpartum weight loss was not significant between the groups (p=0.072).

The trend in weight loss across time was significant in the EBF group (p=0.011) and not the MF group (p=0.067).

Hatsu et al., International Breastfeeding Journal , 2008



Changes in Infant Body Weight with Respect to

Birthweight by Type of Feeding

Anderson AK; International Journal Pediatrics: in press

T d i I f t %BF b



0

5

10

15

20

25

30


Postpartum

% b o d y f a t

Male Female

EBF MF

Trends in Infant %BF by

Gender and Feeding Practice


Pattern of Infant Adiposity by



Pattern of Infant Adiposity by

Type of Feeding

Anderson AK; International Journal of Pediatrics: in press

P tt f L M ith



Pattern of Lean Mass with

Type of Feeding

Anderson AK; International Journal Pediatrics: in press

M t l P W i ht



Maternal Pregnancy Weight

Gain and Infant Adiposity

0

5

10

15

20

25

30


Postpartum

% b o d y f a t

Insufficient Recommended Excessive




Association b/n Maternal Pre-pregnancy

BMI by Weight Gain and Infant Adiposity

0

5

10

15

20

25

30

35

<19.8 19.8-26.0 26.0-29.0 >29.0

Maternal Pre-pregnancy BMI (kg/m2)

%

b o d

y f a

Insufficient Recommended Excessive




Conclusion

Overweight/Obese mothers are less likely

to exclusively breastfeed

Female infants accrued more %BF than

their male counterparts

Maternal pre-pregnancy BMI and

pregnancy weight gain positively

correlated with infant birthweight



Conclusion

There is an indication of a protective effect of EBF

against maternal overweight/obesity and signs of rapid

return to prepregnancy weight even in the early

postpartum period.

The observation that percent body fat loss wassignificant across time within the EBF mothers and not

MF mothers is suggestive of the protective effect of EBF

against cardiovascular disease and other chronic health

conditions. The study clearly shows the importance of encouraging

and supporting mothers to breastfeed exclusively as

recommended by the American Academy of Pediatrics

and the World Health Organization.



Clinical/Public Health Implications

• Provides further evidence to promote

breastfeeding and prevent obesity

• Evidence of dose dependent effect of

breastfeeding duration and prevalence of

obesity

• Breastfeeding has a consistent protective

effect against obesity of children



Acknowledgement

Thank you

• All participants

• ARMC for patient

recruiting

Thank you

• Graduate Students

– Irene Hatsu

– Dawn McDougald – Priyanka Chakraborty

• Recruiter Interviewer

– Linda Garcia



Source of Funding

College of Family and Consumer

Sciences, University of Georgia

Office of the Dean, College of Family and

Consumer Sciences,

University of Georgia

Office of the Vice President for Research,

University of Georgia



Thank You!

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