Running Head: INFANT FEEDING METHODS AND OBESITY

The Correlation Between Infant Feeding Methods and The Risk of Childhood Obesity

Ryanne Fronzaglio, Tricia Hoskin, Alissa Romain and Mariah Snowden

04/05/2016

NURS 3947: Nursing Research

Dr. Valerie ODell

Running Head: INFANT FEEDING METHODS AND OBESITY 1

Abstract

Childhood obesity is a very prevalent concern across the United States. Obesity can lead to a

number of health complications. Extensive research has been and is currently being conducted to

see what can be done to prevent obesity. Studies have suggested that infant feeding methods have

an effect on obesity. To explore the current research of the differences between breastfeeding and

formula feeding, and how they influence the effect on obesity rates, research was obtained from

eight sources. Research shows significant evidence that breastfeeding, compared to formula

feeding, is effective at decreasing childhood obesity. There was no significant evidence linking

formula feeding as a decreasing factor of obesity in children. In fact there is evidence that links

formula feeding to an increased risk of developing obesity. These findings may play an important

role in preventing the increasing problem of obesity in the United States and worldwide.

Keywords: Childhood Obesity, Obesity, Breastfeeding, Formula Feeding, Prevention

The Correlation Between Infant Feeding Methods and The Risk of Childhood Obesity
Running Head: INFANT FEEDING METHODS AND OBESITY 2

Obesity rates across the United States have been rapidly growing leading to severe health

consequences to those who are overweight. Obesity can lead to a number of complications such

as heart disease, stroke, diabetes, and some forms of cancer. With this rapid increase, researchers

have begun to focus their attention on obesity prevention. Researchers have discovered that

obesity is not just a problem occurring among adults but also an increasing problem among

children. Some of the research that has been conducted has looked into whether obesity can be

prevented during childhood and remain effective through adulthood. One aspect that is proving

to be effective in preventing this, is infant feeding methods such as breastfeeding over formula

feeding. Breast milk has been studied for years and researchers have stated that breastfeeding is

the most ideal form of nutrition for infants due to its extensive health benefits. Recent studies

have shown that breast milk has a protective effect against childhood obesity and in some studies

they suggest it carries into adulthood. While formula fed infants have a higher instance of

childhood obesity along with adult obesity. The following Literature Review examines studies

that have been conducted looking at the obesity rate among breastfed and formula fed infants.

Literature Review

Introduction

In order to research what infant feeding method has a protective effect on childhood

obesity, information was obtained from MEDLINE, EBSCOhost, and CINHAL Plus databases.

Eight sources were examined for a complete analysis of breastfeeding versus formula feeding

and its effects on obesity. Through the following literature review, it will become evident that

breastfeeding has a protective effect against childhood obesity. Feeding methods are chosen by

the parent for a variety of reason such as, socioeconomic status and lack of education. With both
Running Head: INFANT FEEDING METHODS AND OBESITY 3

methods of feeding there are behavioral and physiological mechanisms that can explain their

effects on an infant.

Obesity is a huge concern in the United States among children and adolescents. There is a

lot of attention and research conducted on prevention of obesity in children. Obesity is defined

as a BMI at or above the 95 percentile for the childs age and sex (Lefebvre & John, 2012).
th

Excess childhood weight is associated with low self-esteem and behavioral problems as well as

asthma, diabetes, and increased cardiovascular risk. According to Lefebvre and John (2012),

there are links associating breastfeeding being beneficial to decreasing obesity in childhood,

however, confounding variables have to be considered. This includes maternal, child, cultural,

genetic, and environmental variables. Obesity is most prevalent among African Americans. In

2009-2010, 24.3% of non-Hispanic black children and adolescents were considered obese,

compared to 14% of non Hispanic white children. This trend remains in adulthood, with 49% of

all blacks having a BMI >30, compared to 34.3% of all whites (Hess Ofei Mincher, 2015). The

American Academy of Pediatrics recommends breastfeeding infants at least until their first

birthday

Early nutrition during infancy plays an important role in a childs short and long term

health outcomes. This includes becoming overweight through the concept of programming.

Researchers believe that there is a critical window for programming during infancy that can

influence health issues including obesity later in life. Recently infant nutrition has been

examined as an intervention to reduce the chance of developing health problems during

childhood and even into adolescent years. The first few days of life have been identified as the

critical window in the chances of developing obesity in childhood and adolescence. According to

Wendy Oddy (2012), in her systematic review she suggests that breastfeeding is associated with
Running Head: INFANT FEEDING METHODS AND OBESITY 4

a modest reduction in the risk of later overweight and obesity. Typically breastfed infants weigh

less than those formula fed. There are behavioral and physiological mechanisms that can explain

this.

Behavioral mechanisms are learned at a very early age and can continue through

adulthood. Formula feeding promotes more parental control and less self-regulation than

breastfeeding (Oddy, 2012). Formula fed infants are fed based on the judgement of the feeding

parent or caregiver whereas breastfed infants have more say over their intake. A group of low

income mothers that took part in a nutrition survey believe that a heavy infant was a healthy

infant. They also admitted to supplementing the infants diet because they feared their infant was

not getting enough food. Breastfed infants learn self-regulation at an early age. They base their

intake on energy requirements and end their feeding in response to an internal cue. This internal

cue is said to be lost during a formula bottle feeding. Hence, formula-fed infants may be more

likely to have larger meals, further apart, consuming up to 20-30% higher volume than breastfed

infants (Oddy, 2012).

Breast milks composition varies day to day, morning to night, and even feeding to feeding

depending on what the mother is eating and if the milk is foremilk or hindmilk. A mothers milk

exposes an infant to a wide selection of flavors that may influence their food choices later in life.

Breast milk fed infants become less picky eaters and are willing to try new foods as young

children and adolescents. Breast milk varies in fat content during a feed that signals a infant that

the feeding is coming to an end. More recently it was suggested that different levels of

hormones in hindmilk, towards the end of a feed, may signal satiety in the infant, resulting in

cessation of feeding (Oddy, 2012).

Running Head: INFANT FEEDING METHODS AND OBESITY 5

In another study, it was determined that children who are breastfed have a better ability

to know when they are satisfied, as compared to those children who are bottle fed. 109 children

from three years old to kindergarten age were put into categories based on whether they were

directly breastfed, bottle-fed human milk, or fed formula from birth to three months old. Mothers

were asked to self-report their infant feeding methods of choice and how often they used this

method during the first three months of the infants life.

It was found that "direct breastfeeding during early infancy is related to greater appetite

regulation later in childhood" (Disantis, Collins, Fisher, Davey, 2011). Those who chose bottle

feeding were found to have over fed their child beyond their satiety level because, " bottle-

feeding provides visual cues to mothers about the volume of milk consumed, which might

encourage a caregiver to feed more or an infant to eat independent of satiety cues" (Disantis,

Collins, Fisher, Davey, 2011). With breastfeeding rather than using visual cues, the mother uses

cues from the infant, such as a decrease in the infant's sucking or drowsiness as cues the infant

has reached a level of satiation. Another significant finding was, "children fed human milk in a

bottle were 67% less likely to have high satiety responsiveness compared to directly breastfed

children" (Disantis, Collins, Fisher, Davey, 2011).

There is 40 years worth of evidence that support that early nutrition and growth affects

cardiovascular health. Formula fed infants have a higher postnatal growth rate and an earlier

adiposity rebound than breastfed infants (Oddy, 2012). Infant feeding methods also play a role in

adipokines which can occur later in life. Adipokines affects insulin sensitivity and contributes to

a chronic inflammatory state that can possibly play an essential role in type 2 diabetes,

cardiovascular disease, obesity, along with fatty liver disease. On the other end of the growth

spectrum infants who have a lower growth rate require lower energy requirements. This means
Running Head: INFANT FEEDING METHODS AND OBESITY 6

that they are satisfied with breastfeeding for a longer period of time and do not require extra

nutrition such as formula or solid foods.

Moss and Yeaton conducted a study that focused on the relationship between

breastfeeding and the postponing of solid foods on childrens obesity and healthy weight status.

Breastfeeding has been linked to a healthy weight status and decrease in obesity of children at

two and four years old. Data was taken from the nine month, two, and four years waves of the

Early Childhood Longitudinal Study-Birth Cohort (ECLS-B), a nationally representative sample

of US children born in 2001 (Moss and Yeaton, 2014). The study omitted children born to

mothers younger than 16 years old, children who were adopted, and children who had very low

birth rates of less than 1500 grams. The sample size was 7,200 at two years and 6,950 at four

years (Moss and Yeaton, 2014).

Children with percentiles less than 85 were classified as healthy weight. That includes

600 children who were underweight, less than 5 percentile. Children between 85-94 percentiles
th

were considered overweight and those 95 or higher percentile were obese. Breastfed children
th

were more likely than never breastfed children to have healthy weight status at both 2 (68.2 vs.

59.9%) and 4 years old (69.5 vs. 65.4%). Breastfed children also had a lower percentage of

obese weight status than children not breastfed, at both 2 (18.0 vs. 27.0%) and 4 years old (12.7

vs. 18.3%) (Moss and Yeaton, 2014). A second set of meta-analytic results indicated that

breastfeeding was associated with lower levels of childhood obesity and increased likelihood of

desirable weight status for children ages 5-18(Moss and Yeaton, 2014).

Research has led to the development of the growth acceleration hypothesis. Obesity,

cardiovascular disease, dyslipidemia, raised insulin levels, and insulin resistance are all negative

health effects that result from childhood growth acceleration. The growth acceleration
Running Head: INFANT FEEDING METHODS AND OBESITY 7

hypothesis suggests that rapid early weight gain, rather than specific mechanisms that cause it,

may program for later obesity (Oddy 2012). This hypothesis is supported by studies that show

early infant growth for weight and length can lead to an increase risk in obesity. There are a

handful of studies that show breastfeeding results in a rapid weight gain compared to formula in

the first few months but eventually breastfed infants have lower weights later in infancy.

In a study conducted by Sabau et al. (2014), they looked at 179 newborns with birth

weights greater than 4,000 grams (8.82 lbs) born over a period of three months in six large

maternity hospitals in Romania. They found that only 32% of newborns were breastfed at

discharge, 18% were formula-fed, and 50% received mixed feeding. Following a caesarean

section, the chances to breastfeed are lower. Stated in this study, School age children who were

breastfed during their first year of life are at 20% lower risk of obesity compared to those who

were formula fed (Sabau et al., 2014). The differences in the rate of weight gain can be related

to whether the child was breastfed or formula fed. The composition of breast milk provides a

slower pace of growth. Evidence shows that there is increased protein content in formula causing

a risk of obesity.

Formula is said to have 70% more protein than breast milk. Researchers have developed

early protein hypothesis that suggests the high protein content is responsible for an accelerated

growth rate and adiposity during the critical window in infancy. Elevated protein levels in

formula enhances the release of insulin and IGF-1. Both of these things increase the growth in 1-

2 year olds. High insulin levels have been seen in formula fed infants as soon as 6 days postnatal

(Oddy, 2012). These insulin levels cause an increase in fat deposition and premature

development of adipocytes. Breast milk has a protective effect on obesity because it induces

lower blood insulin levels. The lower levels decrease fat storage and prevent premature
Running Head: INFANT FEEDING METHODS AND OBESITY 8

adipocyte development. A recent study that compared the BMI of infants fed high-protein

formula versus low-protein formula was supportive of the early protein hypothesis, showing a

higher BMI values closer to that of breastfed infants in the low-protein group(Oddy, 2012).

Breastmilk has unique bioactive compounds that formula does not have. Breastmilk does have a

high fat content but it has a lower protein content than formula. The most important difference

between breastmilk and formula is that the lower protein content, presence of hormones, and

growth factor found in breastmilk greatly lowers the chances of developing obesity. Overweight

infants are very likely to become overweight children, adolescents, and adults.

Breastmilk is considered the best nutrition for infants with a variety of both short and

long term health benefits. A raise in breastfeeding campaigns has resulted in an increase in

breastfeeding among all ethnicities during the last 20 years. Although there has been an increase

in breastfeeding campaigns in the U.S there is still more nurses and healthcare providers can do

to increase awareness of breastfeeding. There is also more they can do to implement effective

interventions that will encourage a mother to initiate and maintain breastfeeding. The most

important factor in determining the impact of breastfeeding on obesity is duration. The longer the

duration the more significant impact it has on a childs weight.

Policies developed by the American Academy of Pediatrics and the National Association

of Pediatric Nurse Practitioners recommend nurse practitioners encourage patients on adequate

duration of breastfeeding for at least 6 months to ideally 1 year. Lefebvre and John (2012), found

through examination of literature, from 2005 to 2012, that duration of breastfeeding of four

months was shown to be statistically significant in reducing childhood obesity in four studies.

Similarly, they found that children who were breastfed for more than 6 months developed a

leaner body shape by the age of 5. Evidence obtained from a study conducted in 2010 by
Running Head: INFANT FEEDING METHODS AND OBESITY 9

Metzger and McDade compared siblings body mass index. In this study, one sibling was

breastfed and the other was not, resulting in a body mass index at 0.39 standard deviations lower

than the other sibling. The confounding variables were controlled in that study.

In another study, each additional month of breastfeeding was associated with less weight

gain and lower odds of being overweight at one year (Gubbels, Thijs, Stafleu, Van Buuren, and

Kremers, 2011). Data was obtained from the Dutch KOALA Birth Cohort Study which started in

the year 2000. There were 1863 children who participated in the study where their parents

answered questionnaires at three and seven months and one, two, and four years of age (Gubbels,

Thijs, Stafleu, Van Buuren, and Kremers, 2011).

The mothers answered questions pertaining to whether breastfed or bottle-fed, duration of

breastfeeding, whether fed on demand or fed on a schedule, and also snacking habits. They

found that feeding habit, whether on schedule or on demand, was unrelated to weight gain, BMI,

or overweight. Children, on average, gained 37.6 grams less in their first year for each additional

month of breastfeeding (Grubbels, Thijs, Stafleu, Van Buuren, and Kremers, 2011).

Breastfeeding is associated with less unhealthy snacking, as well as protection against unhealthy

weight gain and possibly against obesity (Gubbels, Thijs, Stafleu, Van Buuren, and Kremers,

2011)

Socioeconomic factors have been a major influence for mothers who choose to breastfeed

versus mothers who choose to formula feed their infants as confirmed by Gibbs and Forste. The

study conducted by Gibbs and Forste focused on the relationship between infant feeding

practices, socioeconomic status, and childhood obesity. The data used in this study was

"collected when the child was 9 months of age and 24 months of age, with the dependent

variable, childhood obesity, collected at 24 months of age" (Gibbs and Forste, 2014). A series of
Running Head: INFANT FEEDING METHODS AND OBESITY 10

questions were asked regarding if mothers ever breastfed or formula fed. Mothers who were

considered to be socioeconomically disadvantaged were more likely to engage in infant feeding

practices that were not as healthy, as compared to mothers who are considered to be more

socioeconomically advantaged. Lower socioeconomic classified mothers were more likely to

bottle feed and put their child to bed with a bottle, both of which are linked to childhood obesity.

"Infants predominantly fed formula for the first 6 months were about 2.5 times more

likely to be obese at 24 months of age relative to infants predominantly fed breast milk" (Gibbs

and Forste, 2014). This study confirms that breastfeeding significantly helps reduce the risk of

obesity in children, because "breastfeeding provides a protective effect against excessive

childhood weight gain. Yet, the very children that need this protection the most are also the least

likely to be breastfed" (Gibbs and Forste, 2014). Encouraging and educating mothers who have

children at risk for obesity on the benefits of breastfeeding, is essential to decreasing childhood

obesity.

Conclusion

When looking into the prevention of childhood obesity there is a substantial amount of

research that suggests infant feeding methods play a large role in the possible development of

obesity. Various studies and research suggests that breastmilk has a protective effect against

obesity. Breastfed infants are able to self-regulate their consumption of milk lowering their

chances of overeating. Whereas formula fed infants intake is up to the parent or caretaker's

judgement. Since breastfed infants can self-regulate they only consume the amount of energy

they need resulting in a lower growth rate. Formula fed infants are at a higher risk of overeating

leading to a rapid increase in weight. Formula has 70% more protein than breast milk leading to
Running Head: INFANT FEEDING METHODS AND OBESITY 11

an increase insulin levels. Increased insulin levels lead to increased fat deposits in an infant.

Breastfed infants are also satisfied with breast milk for a longer period of time than formula fed

infants. Formula fed infants will quickly become dissatisfied and will need additional sources of

nutrition such as solid food. The longer the duration of breastfeeding the longer the protective

effect against obesity. Breast milk is considered the most ideal form of nutrition not only

because of its protective effect against obesity but also due to its other extensive health benefits.
Running Head: INFANT FEEDING METHODS AND OBESITY 12

References

Disantis, K. I., Collins, B. N., Fisher, J. O., & Davey, A. (2011). Do infants fed directly from the

breast have improved appetite regulation and slower growth during early childhood

compared with infants fed from a bottle?. The International Journal Of Behavioral

Nutrition And Physical Activity, 889. doi:10.1186/1479-5868-8-89

Gibbs, B. G., & Forste, R. (2014). Socioeconomic status, infant feeding practices and early

childhood obesity. Pediatric Obesity, 9(2), 135-146. doi:10.1111/j.2047-

6310.2013.00155.x

Gubbels, J. S., Thijs, C., Stafleu, A., Buuren, S., & Kremers, S. J. (2011). Association of breast-

Feeding and feeding on demand with child weight status up to 4 years. International

Journal of Pediatric Obesity, 6 (2Part2), e515-e522. doi:10.3109/17477166.2010.514343

Hess, C., Ofei, A., & Mincher, A. (2015). Breastfeeding and Childhood Obesity Among African

Americans: A Systematic Review. MCN. The American Journal Of Maternal Child

Nursing, 40(5), 313-319. doi:10.1097/NMC.0000000000000170

Lefebvre, C. M., & John, R. M. (2012). The effect of breastfeeding on childhood overweight and

obesity: A systematic review of literature. Journal of the American Association of Nurse

Practitioners, 26, 386-401.

Moss, B., & Yeaton, W. (2014). Early Childhood Healthy and Obese Weight Status: Potentially

Protective Benefits of Breastfeeding and Delaying Solid Foods. Maternal & ChildHealth

Journal, 18(5), 1224-1232. doi:10.107/s10995-013-1357-z

Oddy, W. H. (2012). Infant feeding and obesity risk in the child. Breastfeeding Review:

Professional Publication Of The Nursing Mothers' Association Of Australia, 20(2), 7-12.

Sabau, D., Stamatin, M., Stoicescu, S., Filip, V., Cucerea, M., Ognean, L., Miu, N. (2014).
Running Head: INFANT FEEDING METHODS AND OBESITY 13

Correlations among parental and neonatal anthropometric parameters, feeding practices

and infant obesity. Clujul Medical, 87(3), 166-170. Doi: 10.15386/cjmed-294