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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
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Outline
• Overweight/Obesity situation
• Effect of overweight/obesity
• Relation between infant feeding andoverweight/obesity
• Research findings
• Conclusions
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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
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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
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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
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BMI and Body Fat
High Body Fat by BMI-for-Age Category Girls,
8 –19Years, 1999 –2004
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Trends in Obesity Among U.S.
Children and Adolescents
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Prevalence of ObesityChildren and
Teens, 6 –19 Years, 1999 –2008
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Prevalence of Severe Obesity
Children and Teens, 6 –19 Years,
1999 –2008
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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
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• 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
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Annual Medical Cost of
Obesity
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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.
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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.
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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
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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
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Prenatal/Pregnancy TargetsThe Number of Baby Friendly Steps in Place Predicts
Early Breastfeeding Cessation
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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)
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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.
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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.
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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
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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
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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)
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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.
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• 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)
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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
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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)
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Current Research Findings
from my Lab• Evaluating the impact of infant feeding on
maternal and infant body composition
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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
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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
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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
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BOD POD
Image from www.BODPOD.com
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Body Composition Measurement: Infants
• Anthropometric measurements:
– Weight (PEA POD)
– Recumbent length (Seca 416 mechanical
infantometer)
• PEA POD:
– Air displacement plethysmography
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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
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Anderson AK; International Journal of Pediatrics; in press
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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
Anderson et al., Infant, Child and Adolescent Nutrition (ICAN): submitted
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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
Anderson et al., Infant, Child and Adolescent Nutrition (ICAN): submitted
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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).
Anderson et al., Infant, Child and Adolescent Nutrition (ICAN): submitted
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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)
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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
2 wks 4 wks 8 wks 12 wks
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
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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
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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
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0
5
10
15
20
25
30
2 wks 4 wks 8 wks 12 wks
Postpartum
% b o d y f a t
Male Female
EBF MF
Trends in Infant %BF by
Gender and Feeding Practice
Anderson et al., Infant, Child and Adolescent Nutrition (ICAN): submitted
Pattern of Infant Adiposity by
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Pattern of Infant Adiposity by
Type of Feeding
Anderson AK; International Journal of Pediatrics: in press
P tt f L M ith
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Pattern of Lean Mass with
Type of Feeding
Anderson AK; International Journal Pediatrics: in press
M t l P W i ht
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Maternal Pregnancy Weight
Gain and Infant Adiposity
0
5
10
15
20
25
30
2 wks 4 wks 8 wks 12 wks
Postpartum
% b o d y f a t
Insufficient Recommended Excessive
Anderson et al., Infant, Child and Adolescent Nutrition (ICAN): submitted
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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
Anderson et al., Infant, Child and Adolescent Nutrition (ICAN): submitted
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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
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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.
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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
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Acknowledgement
Thank you
• All participants
• ARMC for patient
recruiting
Thank you
• Graduate Students
– Irene Hatsu
– Dawn McDougald – Priyanka Chakraborty
• Recruiter Interviewer
– Linda Garcia
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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
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Thank You!
Questions?