Childhood Obesity
Health Outcomes of
Breastfeeding
Dennette Fend, NP
William Beaumont Hospital
Nutrition and Preventive Medicine
Outpatient Breastfeeding Clinic
March 28, 2014
Outline
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Obesity Epidemics
Etiology of Obesity
Medical and Psychosocial Consequences
Efforts to Reverse the Epidemic –
Health Outcomes of Breast feeding
Obesity Trends* Among U.S. Adults
BRFSS, 1989
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1991
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2003
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 2009
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 2000, 2010
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
2000
1990
Obesity: 35%
Overweight and Obesity: 68%
2010
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Childhood Obesity
(ages 10-17)
• Childhood obesity has more than tripled over the past 3
decades.
• Obesity: 17%
• Overweight & obesity:
35%
Race/Ethnicity and Childhood Obesity
Body Mass Index (BMI)
BMI =
Weight (kg)
Height (m2)
BMI (kg/m2)
Risk of
Comorbidities
Healthy Weight
18.5 – 24.9
Normal
Overweight
25.0 – 29.9
Increased
Obese Class I
30.0 – 34.9
High
Obese Class II
35.0 – 39.9
Very High
Obese Class III
> 40.0
Adapted from the World Health Organization. Obesity: Preventing
and Managing the Global Epidemic. Geneva: WHO; 2000.
Extremely High
Defining
Childhood/Adolescent
Overweight and Obesity
Child Obesity
BMI > 95th %
Child Overwt
BMI > 85th %
and < 95th %
Outline
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Obesity Epidemics
Etiology of Obesity
Medical and Psychosocial Consequences
Efforts to Reverse the Epidemic
Positive Energy Balance Leads to
Weight Gain
Fat
Stores
Saving and Overconsuming Energy
Contributing Factors to Childhood Obesity
Nutrition and Eating Habits:
• Eating less fruits and vegetables than recommended
• Increases in snacking, especially on less healthy food
• Larger portion sizes of food and beverages
• Increases in consumption of sugar sweetened drinks
• More food eaten away from home
• Lack of access to healthy foods at neighborhood stores
Centers for Disease Control
Portion Distortion
30 Years Ago
320 calories
Today
How many calories
today?
Portion Distortion
30 Years Ago
Today
320 calories
820 calories
500 Calorie Difference
Portion Distortion
30 Years Ago
85 Calories
6.5 ounces
Today
How many
calories today?
Portion Distortion
30 Years Ago
Today
170 Calorie
Difference
85 Calories
6.5 ounces
250 Calories
20 ounces
Portion Distortion
BAGEL
30 Years Ago
Today
140 calories
3-inch diameter
How many
calories today?
Portion Distortion
BAGEL
30 Years Ago
Today
140 calories
3-inch diameter
350 calories
6-inch diameter
Calorie Difference: 210 calories
Food Intake per Eating Occasion, oz
Portion Sizes for Americans
Aged 2 years and Older
1977-1978
1989-1991
1994-1998
20
15
10
5
0
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et al.,
JAMA289:
2003; 450-453
289:450-453.
JAMA,
2003;
Soft Drinks: “Liquid Candy”
• Sugar drinks are the largest source of added sugar and an
important contributor of calories in the diets of children in the
United States.
• High consumption of sugar drinks, which have few, if any,
nutrients, has been associated with obesity.
• On a typical day, 80% of youth drink sugar drinks.
Reedy J, J Am Diet Assoc 2010;110(10):1477—84.
Vartanian LR, Am J Public Health 2007;97(4):667—675.
Wang YC, Pediatrics 2008;121(6):e1604—1614.
The School Environment
• ~55 million children are enrolled in schools across the United
States
• > 50% of U.S. middle and high schools still offer sugar drinks
and less healthy foods for purchase
• Children have access to sugar drinks and less healthy foods
at school throughout the day from vending machines and
school stores, as well as fundraising events, school parties,
and sporting events.
Snyder TD, National Center for Education Statistics; 2009.
CDC. Children's Food Environment State Indicator Report, 2011.
Michigan Youth Health Risk Behavior Survey:
High School Students, 2011
• During the 7 days before the survey
– 5% did not eat fruit or drink 100% fruit juices
– 6% did not eat vegetables
– 9% drank a can, bottle, or glass of soda or pop three or
more times per day
www.cdc.gov/yrbss
Contributing Factors to Childhood Obesity
Physical Inactivity:
• Spending more time in front of a screen (television, video
games, computers)
• Less physical activity in schools and at home
• Less walking/biking to school and in the community
• Communities designed for driving, not walking or biking
Centers for Disease Control
Television and Media
• 8 to18 year-olds spend an average of 7.5 hours a
day using entertainment media (TV, computers,
video games, cell phones, and movies)
• 83% of children 6 months to <6 years old view TV
or videos about 1 hour and 57 minutes a day
Rideout VJ, A Kaiser Family Foundation Study;
2010.
Rideout V, The Henry J. Kaiser Family
Foundation; 2006.
TV and Childhood Obesity
• Takes away from the time children spend in
physical activities
• Leads to increased energy intake through snacking
and eating meals in front of the TV
• Influences children to make unhealthy food choices
through exposure to food advertisements
Zimmerman FJ, Am J Public Health
2010;100(2):334—40.
Robinson TN. Pediatr Clin North Am
2001;48(4):1017—25.
.
Physical Activity in Schools
• At least 60 minutes of aerobic physical activity each day is
recommended
• Only 18% of students in grades 9 -12 met this
recommendation in 2007.
• Daily, quality physical education in school could help
students meet the guidelines.
• However, in 2009 only 33% attended daily physical
education classes.
U.S. Department of Health and Human Services. 2008.
Youth Risk Behavior Surveillance System.
http://www.cdc.gov/HealthyYouth/yrbs/pdf/us_physical_trend_yrbs.pdf
Michigan Youth Health Risk Behavior Survey:
High School Students, 2011
• Physical Inactivity
– 66% did not attend physical education (PE) classes in an
average week when they were in school.
– 29% watched television 3 or more hours per day on an
average school day.
– 27% used computers 3 or more hours per day on an
average school day.
www.cdc.gov/yrbss
Outline
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Obesity Epidemics
Etiology of Obesity
Medical and Psychosocial Consequences
Efforts to Reverse the Epidemic
Health Risks of Childhood Obesity
• The current generation of young people could be
the first in U.S. history to live sicker and die younger
than their parents’ generation.
• Nearly one-third of children and teens are currently
obese or overweight, which is putting them at higher
risks for developing a range of diseases and
developing them earlier in life.
Health Risks of Childhood Obesity
• Children who are obese are more than twice as likely to die
before the age of 55 as children with normal BMI
• Around 70% of obese youths have at least one additional
risk factor for cardiovascular disease, such as:
– Elevated total cholesterol
– Elevated triglycerides
– Elevated insulin
– Elevated blood pressure
Health Risks of Childhood Obesity
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Sleep apnea
Asthma
Gallstones
Type 2 diabetes
Hypertension
Orthopedic/joint problems
Fatty liver
Cancer
Poor self esteem/depression
Victims of bullying and social stigma
Eating Disorders
1 out of 3 children born in the year 2000 will
be diabetic during their lifetime.
Risk of Adult Obesity
• Children who are obese after the age of 6 are
50% more likely to be obese as adults.
• For overweight tweens and teens (10 – 15
years old), 80% will be obese as adults.
Psychosocial Consequences
• Overweight and obese children and teens face a
higher risk for:
–
–
–
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more severe and frequent bullying
are rejected by their peers more often
are chosen less as friends
generally not as well-liked as healthy-weight children
• Weight-based teasing is related to increased
susceptibility to depression.
Perceptions
Perceptions
Perceptions
Financial Costs of Obesity
• >25% of all U.S. health care costs are related to obesity and
inactivity. (Anderson, et al 2005)
• 1979 and 1999: Obesity-associated hospital costs for
children tripled from $35 million to $127 million. (Wang and
Dietz, 2002)
• Physical inactivity costs $128 per person. (Garrett, 2004)
• Adult obesity costs $2.9 billion in Michigan. (BRFS 2008)
Outline
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Obesity Epidemics
Etiology of Obesity
Medical and Psychosocial Consequences
Efforts to Reverse the Epidemic
Reducing Childhood Obesity
• Reducing and preventing childhood obesity is
critical to improving the future health of the country,
and consequently would help to lower health care
costs and improve productivity.
• Research supports the concept that focusing on
children and getting them on a healthy path early in
life is one of the areas where the greatest
successes can be achieved.
Breastfeeding & Obesity
• Breast feeding during infancy has been shown to
reduce the risk of infants developing overweight
and/or obesity in childhood.
• The risk of overweight in children decreases by
30% with 9 months or more of breastfeeding and
each month of breastfeeding was associated with a
4% decrease in the risk of overweight into
childhood.
Tawia, S. Breastfeeding Review. 2013
Long term health benefits
Dose response
gradient- better with
prolonged, exclusive
breastfeeding!
Gunderson, EP. 2008.
Curr Diab Rep.
Why does BF
protect against obesity?
• Feeding from the breast prevents over feeding
(feeding beyond satiety)– babies do not take in
more than they need.
• BREAST FEEDING rather than BREAST MILK
protects against obesity in later life.
• SELF-REGULATION!
• Baby led weaning: babies continue to self-regulate
their intake.
» Li, R. Arch Pediatric Adolesc Med. 2012
How?
• Baby led weaning provides infants, from about 6
months, the opportunity to continue to self-regulate
their food intake – very successfully!
• Babies who are breastfed less likely to over consume
calories compared to formula fed infants = less likely
to become overweight/obese as they grow older.
• BF babies are not encouraged to “finish the bottle”.
They learn self-regulation of caloric intake more
closely suited to their needs.
• Substances pass from mom to baby - such as the
appetite-regulating hormone leptin.
AICR. August 2012. Issue 73.
Definition of LEPTIN
• : a peptide hormone that is produced by fat
cells and plays a role in body weight
regulation by acting on the hypothalamus to
suppress appetite and burn fat stored in
adipose tissue
http://www.merriam-webster.com/medical/leptin
Babies drink more from
bottle than breast
Why?
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1. Working moms: pumped milk is costly – finish bottle.
2. Sharing in responsibility of feeding.
3. Empty bottle/clean plate satisfying to
parents/caregivers.
4. Infants with slow initial weight gain more likely to
receive formula for risk of under nutrition
5. Want to know how much child is eating.
» Li, R. Arch Pediatric Adolesc Med. 2012
Appetite regulation
• STUDY: Does feeding human milk from breast
or bottle lead to better appetite regulation in
childhood?
• Children aged 3-6 y/o categorized into directly,
exclusively BF, bottle fed human milk, or bottle
fed formula in first 3 months
• Direct BF associated with greater appetite
regulation
• Children bottle fed human milk 67% less likely to
have high satiety response compared to those
directly BF
»
DeSantis, K. (2011). Int’l Journal of Behavioral Nutrition
and Physical Activity.
Childhood obesity
• October 13 - Japanese study showed exclusive
breastfeeding at 6-7 months was associated with
decreased risk of being overweight and obesity
compared to formula feeding.
• Results effective through 7-8 years of age among
Japanese schoolchildren.
Yamakawa, M. JAMA. 2013.
BF reduces obesity
• BF reduces body size, visceral fat,
subcutaneous fat, and protects against
central fat patterning of youths at higher
fat levels.
» Crume et al. (2012). Int’l Journal of
Obesity
Delaying Solid Food
• Analyses of breastfeeding practice combinations
revealed that when children were not breastfed,
obesity odds decreased when solid foods
postponed until 4 months of age.
• Obesity odds were further decreased when solid
food delay was combined with breastfeeding.
• Consistent increases in delaying complementary
foods = consistently and substantially lower
likelihood of obesity.
Prevention of Type 1 Diabetes
Most studies indicate that BF:
 Offers a protective effect against development T1DM
 Shorter duration of BF could be a modifiable risk factor in
development of T1DM.
 Duration of BF and age at intro to bottle feeding are
inversely associated with T1DM (>5 months compared to <2
weeks).
» J Pediatr (Rio J). 2013 Oct 16. pii: S00217557(13)00178-2
Breast vs formula
Why do breast-fed babies have a decreased risk of
developing T1DM?
– Due to a cell mediated response to a specific cow’s milk
protein (beta-casein) which may be involved in the
pathogenesis of type 1 diabetes mellitus
Prevention of T1DM
Pooled data 43 studies:
Overall risk reduction of DM after exclusive BF for
>2 weeks
Association for >3 months a bit weaker, but results
vary
No association after non-exclusive BF for >2 weeks
or >3 months
 Author cites marked variation in effect and possible
biases
» Cardwell, CR et al. Diabetes Care. 2012
Nov;35(11):2215-25.
Early nutrition matters!
Risk of T1DM increased if:
 Starting solids <4 months of age or >6 months
 Safest age to introduce solids 4-5 months
 BF while introducing new foods may decrease
risk T1DM
Frederiksen, B. JAMA Pediatr. 2013
Sep;167(9):808-15.
Questions?
Contact info:
Dennette Fend, MSN, NP, IBCLC
dfend@beaumont.edu
Thank you