Breastfeeding and obesity: a meta-analysis

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  • 1. Vol.1, No.3, 88-93 (2011) Open Journal of Preventive Medicinedoi:10.4236/ojpm.2011.13013Breastfeeding and obesity: a meta-analysisJeanne M. StolzerUniversity of Nebraska-Kearney, Kearney, USA; stolzerjm@unk.eduReceived 3 September 2011; revised 15 October 2011; accepted 24 October 2011.ABSTRACT have significantly increased their consumption of fatty fast foods [1]. In addition, trans-fats are now a commonOver the last decade, obesity rates have reached ingredient in a variety of foods and natural home pre-epidemic proportions in the United States of A- pared meals are becoming increasingly rare.merica. Comorbidities associated with overweight In addition, Americans are now more sedentary thanand obesity include, but are not limited to, hy- at any time in recorded history. Walking, which has beenpertension, type 2 diabetes, cardiovascular di- an integral feature of hominid existence throughout evo-sease, and elevated cholesterol levels. As a di- lutionary time, has now been replaced by riding in cars,rect result of obesity, data indicates that these elevators, and other automated means of transportationdiseases are now being detected in an unpre- [2]. Children no longer spend their days engaged in rig-cedented number of American children, ado- orous physical outdoor activity, but instead rely on high-lescents, and adults. Although the major cause tech gadgetry to occupy their time [3]. Physical educa-of the obesity epidemic in America has thus far tion classes have been systematically reduced or elimi-been attributed to excessive caloric intake and nated, and recess is no longer considered a necessarylack of physical activity, this paper will explore component of the American public school curriculumthe pivotal role that breastfeeding plays in the [3,4].prevention of overweight and obesity through- According to the American Academy of Pediatrics [5],out the life course. Epidemiological data demon- prevention of obesity in children must be the first line ofstrates that breastfeeding significantly reduces defense. The American Academy of Pediatrics [5] re-the incidence of overweight and obesity and leased a policy statement that recommended that pedia-that exclusive and long term breastfeeding has tricians should become adept at recognizing children atbeen strongly correlated with a reduction in LDL risk of overweight and obesity. In addition, pediatricianscholesterol, blood pressure related disorders, should calculate and plot Body Mass Index (BMI) attype 2 diabetes, and cardiovascular dysfunction. every visit, use changes in BMI to identify excessiveWhile it is certain that diet and exercise are in- weight gain, and monitor for comorbidities associatedtegral factors associated with overweight and with obesity. The American Academy of Pediatrics [5]obesity, the time has come for a collective re- also states that pediatricians should encourage, support,cognition of the protective effects associated and protect breastfeeding in order to significantly de-with breastfeeding if we are serious in our en- crease overweight and obesity in child populations [2,5].deavor to eradicate the overweight and obesity It is interesting to note that at the same time theepidemic in America. American Academy of Pediatrics (AAP) [5] is promot- ing the multifarious benefits of breastfeeding, they areKeywords: Obesity; Breastfeeding and Obesity; also aligned economically with the formula industry.Breastfeeding; Lactation and Obesity The AAP [5] routinely advertises formula in the presti- geious medical journal “Pediatrics,” was granted three1. INTRODUCTION million dollars by the manufacturers of formula to build Over the last 40 - 50 years, much attention has been the AAP headquarters in Illinois, and is funded in partgiven to the role of diet and exercise with regard to the by block grants provided by the formula industry [6,7].prevention of obesity. It is certainly a fact that the If the AAP [5] is sincere in its efforts to promoteAmerican diet has been altered dramatically in a rela- breastfeeding as a means to combat overweight and obe-tively short time. Portion sizes in food outlets have more sity, perhaps the time has come to sever its economicthan doubled over the last two decades, and Americans ties with the formula industry. Margolis [8] forcefullyCopyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
  • 2. J. M. Stolzer / Open Journal of Preventive Medicine 1 (2011) 88-93 89reiterates this position by stating “The acceptance of It has been established that cow milk contains signify-gifts in virtually any form violates the fundamental du- cantly higher levels of protein and fat than human milk.ties of the physician of nonmaleficence, fidelity, justice, The high fat and protein levels found in bovine basedand self improvement; the medical community must formula lead to an increased secretion of IGF-1 (insulinarticulate this position clearly, and it should act accord- growth factor type 1) and in turn stimulates the over-ingly” (p. 51). production of adipocytes which has been associated with Clearly, the prevention of this epidemic should be our overweight and obesity in human populations [23]. Hu-focus as data confirms that a high body mass index (BMI) man milk is compositionally distinct from all otherin childhood is a strong predictor of overweight and mammalian milk as milk from a particular mammal isobesity during adolescence and adulthood [9]. Increasing species specific (i.e., ensures the optimal development ofbreastfeeding initiation and duration will, according to that particular mammal). Cow milk contains three timespublished data, significantly decrease overweight and the amount of protein that human milk contains, as theobesity, thus decreasing morbidity and mortality rates survival of most mammals is dependent on the rapidacross the life span [10,11]. Obesity related diseases acceleration of physical growth. However, humans aresuch as cardiovascular disease, high blood pressure, ele- distinct from most mammals in this respect [24].vated cholesterol, and type 2 diabetes are manifested in Human milk is quantitatively different than formulaboth children and adults, therefore, early intervention is regardless if it is soy or bovine based. Numerous bioac-critical [5,12]. tive factors are exclusive to human milk, including spe- cific human growth hormones and growth factors which2. BENEFITS OF BREASTFEEDING impact differentiation, growth, and functional maturation In keeping with the guidelines set forth by the Sur- of the human organism [25,26].geon General of the United States [13] and the World The concept that early nutritional intake influencesHealth Organization [11], infants should be exclusively adult onset overweight and obesity was first developedbreastfed for the first six months of life, with continued by McCance [20] in the 1960’s. Kramer [18] continuedbreastfeeding for two years or longer. According to on with McCance’s seminal work and demonstrated withdecades of empirical, epidemiological data, breastfeed- empirical case-controlled studies that formula feeding ining has been associated with significant decreases in infancy was significantly linked to obesity in adoles-morbidity and mortality rates across the life course [13]. cence and adulthood. Animal studies have also been va-Breastfeeding has also been correlated with a reduction luable as they show the particular mechanisms that linkof infectious and noninfectious diseases, diarrhea, respi- early nutrition with accelerated growth, appetite regula-ratory illness, ear infection, type 1 and 2 diabetes, celiac tion, and the underlying hormonal factors which havedisease, inflammatory bowel disease, childhood cancer, been correlated with overweight and obesity in humanallergies, asthma, overweight, and obesity [14,15]. subjects [27]. Numerous scientific studies have confirmed that chil- It has been suggested that one of the reasons that for-dren who are breastfed exclusively and long term are mula-fed infants are more likely to develop overweightless likely to develop botulism, bacterial meningitis, and obesity later in life is that there are predetermined amounts of formula that a baby is supposed to drink.urinary tract infection, liver disease, and sudden infant Physicians and/or the manufacturers of formula recom-death syndrome (SIDS) [14,16]. Furthermore, research- mend specific dosages which often times leads to over-ers have found that breastfeeding significantly decreases eating and the inability to determine satiety [25]. Con-hospital admission rates and prescription drug use in versely, a breastfed baby has no predetermined amountpediatric populations [14,17]. they are supposed to drink at each feeding. Across mam- malian species, the exclusively breastfed baby suckles3. BREASTFEEDING AND OBESITY: until satisfied. There is no overfeeding and the infant EPIDEMIOLOGICAL EVIDENCE learns appetite regulation beginning immediately after For over forty years, epidemiological studies have birth [28].demonstrated that breastfeeding significantly reduces Longitudinal data demonstrates that breastfeeding actsboth overweight and obesity in child, adolescent, and as a buffer against overweight and obesity even whenadult populations [18-20]. In addition, empirical data has controlling for confounding variables such as socioeco-confirmed that nutritional intake in infancy is highly nomic status, education of parents, race, number of sib-correlated with later predisposition to diseases such as lings, and maternal BMI [29,30]. Gillman and Collea-obesity, high blood pressure, heart disease, and type 2 gues [31] found that the effects of breastfeeding arediabetes [21,22]. dose-response specific, as their data indicates that theCopyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
  • 3. 90 J. M. Stolzer / Open Journal of Preventive Medicine 1 (2011) 88-93longer a child is breastfed, the less likely the child is to terol, and cardiovascular disease.become overweight or obese in later life. Armstrong & Reilly [29] assessed 32, 2000 children 5. TYPE 2 DIABETESand found the most statistically powerful results were The rates of type 2 diabetes are higher now then atdetected in exclusively breastfed populations. Those any other time in recorded American history [2]. Over-subjects who were formula fed in infancy were signify- weight and obesity are thought to precipitate type 2 dia-cantly more likely to develop overweight and obesityduring later childhood. These results are critical as they betes by interfering with insulin signaling as excess fatdemonstrate the protective effects of exclusive breast- in the muscle cells leads to physiological atrophy result-feeding as opposed to formula feeding or breastfeeding ing in hyperglycemia and chronic glucose intoleranceusing formula supplementation. [35]. Exclusive breastfeeding has been found to protect Bergman, et al. [32] conducted a longitudinal birth individuals from type 2 diabetes by encouraging optimalcohort study that tested whether exclusive breastfeeding lipoprotein metabolism and gastrointestinal adaptationwas correlated with BMI at six years of age. They [2].looked at newborns with almost identical BMI’s, and Exclusive breastfeeding has also been correlated withrevisited these infants at three months of age, and at four, lower fasting insulin concentrations and lowered pre-five, and six years of age. At every interval, the formula prandial blood glucose levels in adults [36]. Ravelli [37]fed children had significantly higher BMI’s and thicker studied a cohort of subjects that were born between 1943skin folds than the breastfed cohort. At the ages of four and 1947 in Amsterdam. Ravelli’s data revealed thatthrough six, the prevalence of obesity tripled in the for- those adults who were exclusively breastfed were sig-mula fed population. nificantly less likely to be diagnosed with type 2 diabe- Other researchers have found that breastfeeding sig- tes when compared to those subjects who were partiallynificantly decreases overweight and obesity in childhood or exclusively formula fed.regardless of maternal diabetes status, or weight status Although investigations are still ongoing, there exists[33]. Gillman and Colleagues [31] work demonstrates substantial evidence to support the supposition thatthat overweight during adolescence predicts short and breastfeeding acts as a buffer with regard to the develo-long term morbidity as well as obesity in adulthood. pment of type 2 diabetes in child, adolescent, and adultAccording to Gillman, et al, formula feeding in infancy populations [5,9,13,15,36].is a significant predictor of adult overweight and obesityeven when controlling for variables such as gender, en- 6. ELEVATED BLOOD PRESSURE ANDergy intake, time watching TV, physical activity, mo- CHOLESTEROLther’s BMI, and socioeconomic status. According to the World Health Organization [15], Decades of systematic reviews of epidemiological elevated blood pressure in adolescence and adulthoodstudies (cohort, case-control, cross-sectional, and longi- has been correlated with formula feeding in infancy.tudinal studies) have compared breastfed and formula Martin and Colleagues [38] conducted a systematic re-infants. These studies have adjusted for a multitude of view which included over 17,000 adults and found thatconfounding variables such as gender, race, age, mater- systolic blood pressure was significantly lower in sub-nal status, parental education, birthweight, and geo- jects who were exclusively breastfed during infancy.graphical location. All of these studies have concluded Martin, et al., [38] acknowledged that the particular me-that breastfeeding plays a significant role in reducing chanisms underlying these findings are not fully under-overweight and obesity in child, adolescent, and adult stood at this time, and that more research is needed inpopulations [18,32,33]. Additional research have clearly this area.demonstrated the dose-response specifity of breastfeed- Plagemann & Harder [39] found that breastfeedinging as data confirms that the longer a child is breastfed, positively impacts both HDL and LDL cholesterol levelsthe stronger the protective effect of breastfeeding against and significantly reduces blood pressure in adolescentsoverweight and obesity throughout life [31,34]. and adults. Waterland & Garza [22] hypothesized that the metabolic imprinting that occurs with formula feed-4. COMORBIDITIES ASSOCIATED WITH ing actually alters vascularization and cell structure OVERWEIGHT AND OBESITY causing changes in the production of enzymes, hormones, Numerous studies have concluded that breastfeeding and transmembrane transporters. Waterland & Garza [22]not only decreases the prevalence of overweight and suggest that this metabolic alteration significantly in-obesity, but is also inversely related to the development creases the risks of later cardiovascular disease.of type 2 diabetes, elevated blood pressure and choles- Although numerous studies have indicated that exclu-Copyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
  • 4. J. M. Stolzer / Open Journal of Preventive Medicine 1 (2011) 88-93 91sive breastfeeding has been associated with a protective ever, any discussion regarding increasing breastfeedingeffect against elevated blood pressure and elevated cho- rates in America must take into account the multifariouslesterol levels later in life [40], researchers have ac- variables associated with this issue. In order to increaseknowledged that the mechanisms which regulate lipo- breastfeeding rates across diverse populations, research-protein concentrations and blood pressure functioning ers must acknowledge the complexities associated withneed further investigation. What is certain at this point is breastfeeding, which include, but are not limited to 1)that breastfeeding is statistically related to the prevention The lack of breastfeeding role models in the family, theof metabolic atrophy in human populations [15,25,40]. community, and the mass media [28]; 2) federal policies which impede both the initiation and duration of breast-7. CARDIOVASCULAR ATROPHY feeding [6,17]; 3) culture ideologies which dictate that a woman’s worth is based on her economic earning power A number of studies have indicated that elevated BMI [28]; 4) the lack of physician breastfeeding educationis correlated with cardiovascular disease [5,9,15,35], and [13,16] and 5) The mass sexualization of the femalethat childhood overweight and obesity are significant breast [7,16].predictors of later cardiovascular, dysfunction [2,41,2]. The Surgeon General [13] has stated that increasing Published data indicates that formula feeding increases breastfeeding rates is essential, and has urged research-the risks of later cardiovascular disease. Rich-Edwards, ers to improve the public’s understanding of the com-et al., [42] examined over 87,000 individuals observing pendious benefits associated with breastfeeding [13]. Atdifferences in feeding methods and later cardiovascular the present time, the United States of America has one ofmalfunction. Participants were born between 1921 and the lowest breastfeeding rates in the world, and contin-1946 and reported in 1992 if they were breastfed or for- ues to rank significantly higher than other industrializedmula fed, and for how long they were breastfed. During nations in terms of morbidity and mortality rates [15]. Ifeight years of investigation, these researchers found that we are to see a reduction in overweight and obesity,breastfed populations had significantly lower rates of American’s can no longer afford to ignore the protectivecardiovascular disease and stroke. The most significant effects of breastfeeding which have been well docu-protective effects of breastfeeding were observed in mented in the medical literature.those participants who were breastfed for nine months or In light of the overwhelming body of scientific evi-longer. dence that documents the risks associated with formula Owen, Whincup, Odoki, Gilg, and Cook [43] cross feeding, the medical profession, parents, researchers,sectional study suggests that breastfeeding plays a major educators, and concerned others must strengthen theirrole in the prevention of cardiovascular disease. Ac- advocacy of breastfeeding. We can no longer claim thatcording to this study, breastfeeding is associated with breastfeeding and formula feeding are equal methods oflower LDL cholesterol and blood pressure, and has long nutrition, or that health outcomes are the same forterm benefits for cardiovascular functioning. breastfed and formula fed populations. The widely known Muscatine Study demonstrated that Data confirms that breastfeeding in infancy is associ-cardiovascular risk in adulthood is related to childhood ated with a reduced risk of overweight and obesity, typeLDL cholesterol levels and childhood BMI [41]. In addi- 2 diabetes, elevated blood pressure and cholesterol, andtion, postmortem studies have indicated that with regard cardiovascular disease [5,11,12,36]. While the decreaseto atherosclerosis, the extent and severity of cardiovas- in caloric intake and an increase in physical activity arecular disease is highly correlated with elevated BMI and the primary environmental protections against over-lipoprotein levels [2]. weight and obesity, preventative strategies such as in- Researchers have postulated that infant nutrition is a creasing breastfeeding initiation and duration rates arereliable predictor of later cardiovascular functioning. essential if we are to be successful in reversing theTracy, Newman, Wattigney, and Berenson [44] con- overweight and obesity epidemic in future generationscluded that atrophy of the arterial wall most likely oc- [5]. Accordingly, we must address this obesity crisis bycurs during childhood as data indicates that formula making breastfeeding a public health priority, and byfeeding in infancy is a more powerful predictor of car- uniting forces across disciplines to support a strong anddiovascular disease then is adult risk factors. effective public health campaign to increase breastfeed- ing rates exponentially [10,11].8. CONCLUSIONS 9. FUTURE DIRECTIONS It has been well established that breastfeeding signify-cantly decreases overweight and obesity and those co- Extensive epidemiological data demonstrates that ex-morbidities associated with these conditions [5,15]. How- clusive breastfeeding has long term benefits includingCopyright © 2011 SciRes. Openly accessible at http://www.scirp.org/journal/OJPM/
  • 5. 92 J. M. Stolzer / Open Journal of Preventive Medicine 1 (2011) 88-93the reduction of obesity and overweight, type 2 diabetes, ment: The prevention of pediatric overweight and obesity.blood pressure, LDL cholesterol levels, and cardiovas- Pediatrics, 110, 496-507. [6] Baumslag, N. and Michels, B. (1995) Milk, money, andcular disease [5,10,15,37]. The inverse relationship be- madness: The culture and politics of breastfeeding. Ber-tween breastfeeding and the above stated risk factors can gin and Garvey, London.no longer be ignored. According to decades of published [7] Palmer, G. (1991) The politics of breastfeeding. Harperempirical data, breastfeeding significantly impacts health Collins, London.outcomes not only in childhood, but throughout the [8] Margolis, L. (1991) The ethics of accepting gifts fromlife-span [14,16,11]. pharmaceutical companies. Pediatrics, 88, 39-54. [9] Goran, M. (2001) Metabolic precursors and effects of In order to increase breastfeeding rates exponentially, obesity in children: A decade of progress, 1990-1999.experts have suggested the following: American Journal of Clinical Nutrition, 73, 158-171. Requiring that the formula industry inform the Ame- [10] Deckelbaum, R. and Williams, C. (2001) Childhood obe- rican consumer of the risks associated with their pro- sity: The health issue. Obesity Research, 9, 239-243. duct [7,16]. doi:10.1038/oby.2001.125 [11] World Health Organization (2007) Evidence on the long Incorporating breastfeeding role models in the famil- term effects of breastfeeding: Systematic reviews and ial sphere, the community, and the mass media [7]. meta-analyses. Geneva, Switzerland, 1-52. Regulating the advertising of formula, particularly in [12] Freedman, D., Dietz, W., Srinivasan, S. and Berenson, G. medical journals and parenting magazines [7]. (1999) The relation of overweight to cardiovascular risk Demanding that the economic alliance between the factors among children and adolescents: The Bogalusa medical community and the formula industry be sev- Heart Study. Pediatrics, 103, 1175-1182. doi:10.1542/peds.103.6.1175 ered, including a halt to the formula industry’s fund- [13] United States Department of Health and Human Services ing of medical research, as well as its practice of giv- (2000) HHS Blueprint for action on breastfeeding. ing free samples to new mothers via hospitals or Washington, DC. physician offices [28]. [14] American Academy of Pediatrics (2005) Policy State- Reassessing America’s cultural view of the female ment: Breastfeeding and the use of human milk. Pediat- breast [16,28]. rics, 115, 496-506. doi:10.1542/peds.2004-2491 [15] World Health Organization (2000) Obesity: Preventing Providing mandatory continuing breastfeeding edu- and managing the global epidemic. World Health Or- cation for practicing physicians [16,17]. ganization, Series 894, Geneva, Switzerland. Formally questioning the ethics of medical journals [16] Stolzer, J. and Hossain, S. (2005) Physician breastfeed- that carry advertisements for formula (a product that ing education: A regional assessment. The Female Pa- is known to increase morbidity and mortality rates) tient, 30, 59-71. [28]. [17] Stolzer, J. and Zeece, P. (2006) Low income women and physician breastfeeding advice: A regional assessment. Demanding that the public be informed via public Health Education Journal, 65, 158-176. service announcements of the protective effects of doi:10.1177/001789690606500203 breastfeeding. [18] Kramer, M. 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