Impact of Infant Feeding on Postpartum Body Composition

Alex Kojo Anderson, PhD, MPH, CPH Dept. of Foods and Nutrition The University of Georgia

Outline
Overweight/Obesity situation Effect of overweight/obesity Relation between infant feeding and overweight/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: Normal weight: Overweight: Obese: BMI < 18.5 kg/m2 BMI = 18.5-24.9 kg/m2 BMI = 25.0-29.9 kg/m2 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, 819Years, 19992004

Trends in Obesity Among U.S. Children and Adolescents

Prevalence of ObesityChildren and Teens, 619 Years, 19992008

Prevalence of Severe Obesity Children and Teens, 619 Years, 19992008

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

Medical Complications Associated with Overweight/Obesity

Respiratory Disorders
Hypoventilation syndrome Sleep apnea Asthma (BMI > 85th percentile)

Hyperinsulinemia
Slight increase in prevalence at 85-90th BMI percentiles Dramatic increase in risk above 97th BMI percentile Impaired glucose tolerance

Non-Insulin Dependent Diabetes (Type 2)

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 (1219 y.o.) 15.3% of school-age children (611 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 20072008

Children and teens (219 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 Targets
The 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; OCallaghan 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-challenge glucose 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 Practice

Exclusive Breastfeeding Age (yrs) Years of formal education Gestational age at delivery (wks) Prepregnancy weight (kg) Maternal height (cm) Prepregnancy BMI (kg/m2) Maternal weight at 36 weeks gestation (kg) Maternal weight at delivery (kg) Pregnancy weight gain (kg) Infant birthweight (kg) Infant birth length (cm) 30.5 5.7 17.5 2.3 39.5 0.9 62.9 10.2 164.7 6.7 23.2 4.2 74.8 10.0 Mixed Feeding 29.0 4.4 17.0 2.9 39.2 1.0 67.2 12.5 160.9 5.7 25.4 5.1 81.6 10.6

75.9 10.2 15.1 4.0 3.4 0.4 51.3 1.9

82.9 10.7 15.4 4.5 3.5 0.5 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) Maternal data Age (yr) Height (m) Pre-pregnancy weight (kg) Pre-pregnancy body mass index (kg/m2) Maternal weight at 36 weeks gestation (kg) Maternal weight at delivery (kg) Pregnancy weight gain (kg) Gestational age at delivery (wks) Years of education Parity Primiparous Multiparous Marital status Single Married 30.45.2 1.60.1 66.213.2 24.75.9 77.112.5 78.512.6 14.93.9 39.40.8 17.22.6 7 (38.9) 11 (61.1) 2 (11.1) 16 (88.9) 15 (83.3) 3 (16.7) Male (n=22) 29.65.0 1.60.1 61.18.5 22.72.8 75.88.3 76.98.9 15.44.3 39.40.9 17.62.6 9 (40.9) 13 (59.1) 2 (9.1) 20 (90.9) 19 (86.4) 3 (13.6)

Race/Ethnicity White Black

Infant data Birthweight (kg) Birth length (cm)

3.40.5 50.61.7

3.60.4 52.02.2

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

Participant characteristics and their associations with gestational weight gain

n (%) Age of Participant < 25 years 25 years Education College graduate More than College Race/ethnicity* White Black Marital Status Married Single Employment Status Full-time Part-time Unemployed Delivery Type Vaginal Caesarean section Parity Primiparous Multiparous Prepregnancy BMI (kg/m2) < 19.8 19.8-26.0 26.0-29.0 29.0 Gestational weight gain (kg) (mean SD)

5 (12.5) 35 (87.5)
16 (40.0) 24 (60.0) 35 (87.5) 5 (12.5) 36 (90.0) 4 (10.0) 23 (57.5) 12 (30.0) 5 (12.5)

13.4 2.8 15.4 4.2

16.4 4.6 14.3 3.5 15.7 4.0 11.8 3.1 15.4 4.2 12.9 1.3 15.7 3.8 13.9 4.8 15.4 3.9 15.5 4.3 13.8 3.2 16.5 3.9 14.5 4.1 12.4 1.1 15.9 4.1 15.6 4.4 11.8 2.8

31 (77.5) 9 (22.5) 13 (32.5) 27 (67.5) 3 (7.5) 27 (67.5) 6 (15.0) 4 (10.0)

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

Proportion of mothers who gained insufficient, recommended and excessive weight during pregnancy by pre-pregnancy BMI*
Pregnancy Weight Gain Pre-pregnancy BMI Insufficient weight gain (%) Recommended weight gain (%) Excessive weight gain (%)

<19.8 kg/m2 (n=3)

19.826.0 kg/m2 (n=27) 26.029.0 kg/m2 (n=6) >29.0 kg/m2 (n=4)

33.3
3.7 0.0 0.0

66.7
55.6 16.7 0.0

0.0
40.7 83.3 100.0

*The percentage of mothers who gained insufficient, recommended and excessive weight gain during pregnancy by pre-pregnancy BMI category differed between categories (x2 = 14.6, p<0.024).

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

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 and overweight/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 on prolactin (Rasmussen & Kjolhede, 2004; Hilson et al., 2006)

Weight change (kg)

8 6 4 2 0 2 wks 4 wks Duration Exclusive breastfeeding Mixed Feeding 8 wks 12 wks

Maternal postpartum weight change with respect to prepregnancy weight

2 wks 0 -2 -4 -6 -8 -10 -12

Weight Change (kg)

4 wks

8 wks

12 wks

Maternal postpartum weight loss with respect to weight at delivery

Duration
Exclusive breastfeeding Mixed Feeding

Hatsu et al., International Breastfeeding Journal, 2008

Pattern of postpartum maternal weight loss by feeding group

6 EBF

Weight change in kg

5 4 3 2 1 0 4 weeks

MF

8 weeks

12 weeks Time

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

Trends in Infant %BF by Gender and Feeding Practice

30
Male EBF Female MF

25

20

% body fat

15

10

0 2 wks 4 wks 8 wks 12 wks

Postpartum

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

Pattern of Infant Adiposity by Type of Feeding

Anderson AK; International Journal of Pediatrics: in press

Pattern of Lean Mass with Type of Feeding

Anderson AK; International Journal Pediatrics: in press

Maternal Pregnancy Weight Gain and Infant Adiposity

30 25 Insufficient Recommended Excessive

% body fat

20 15 10 5 0 2 wks 4 wks 8 wks 12 wks

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

Association b/n Maternal Pre-pregnancy BMI by Weight Gain and Infant Adiposity
35 30 Insufficient Recommended Excessive

% body fat

25 20 15 10 5 0 <19.8 19.8-26.0 26.0-29.0 >29.0 Maternal Pre-pregnancy BMI (kg/m2)

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

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 was significant 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!

Questions?