Michael W. Moramarco

Reduced breastfeeding rates among obese mothers: a review of contributing factors, clinical considerations and future directions.

Maternal obesity is associated with significantly lower rates of breastfeeding initiation, duration and exclusivity. Increasing rates of obesity among reproductive-age women has prompted the need to carefully examine factors contributing to lower breastfeeding rates in this population. Recent research has demonstrated a significant impact of breastfeeding to reduce the risk of obesity in both mothers and their children. This article presents a review of research literature from three databases covering the years 1995 to 2014 using the search terms of breastfeeding and maternal obesity. We reviewed the existing research on contributing factors to lower breastfeeding rates among obese women, and our findings can guide the development of promising avenues to increase breastfeeding among a vulnerable population. The key findings concerned factors impacting initiation and early breastfeeding, factors impacting later breastfeeding and exclusivity, interventions to increase breastfeeding in obese women, and clinical considerations. The factors impacting early breastfeeding include mechanical factors and delayed onset of lactogenesis II and we have critically analyzed the potential contributors to these factors. The factors impacting later breastfeeding and exclusivity include hormonal imbalances, psychosocial factors, and mammary hypoplasia. Several recent interventions have sought to increase breastfeeding duration in obese women with varying levels of success and we have presented the strengths and weaknesses of these clinical trials. Clinical considerations include specific techniques that have been found to improve breastfeeding incidence and duration in obese women. Many obese women do not obtain the health benefits of exclusive breastfeeding and their children are more likely to also be overweight or obese if they are not breastfed. Further research is needed into the physiological basis for decreased breastfeeding among obese women along with effective interventions supported by rigorous clinical research to advance the care of obese reproductive age women and their children.

Food security, maternal feeding practices and child weight-for-length

BACKGROUND Over consumption of energy-dense nutrient-poor foods may contribute to childhood obesity. We hypothesized that greater than recommended servings of sugar sweetened beverages and foods, indicators of food security, and a high maternal recumbent weight-for-length are positively associated with high percentages of child overweight/obesity. METHODS This secondary data analysis consisted of a sample of 240 mother-child dyads. The original studies were designed to examine the effect of a public health nursing intervention on optimal childhood growth for low-income, minority children. Eligibility to participate included: 1) mothers self-identified as Hispanic; 2) children were 12-24 months old; and 3) children were enrolled in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC); and 4) children were free of any major disease. Multivariate logistic regression examined the association between child weight, weight-for-length, maternal recumbent weight-for-length, childs eating schedule, maternal attitudes on feeding, food security, and consumption of sugar-sweetened beverages, desserts and fatty meats. RESULTS Receiving SNAP was positively associated with child weight-for-length (WL). Children whose mothers reported ever having received SNAP were 2.01 times more likely to be overweight compared to children whose mothers did not report ever having received SNAP (95% CI=1.04-3.90). Children who consumed desserts were 2.87 times more likely to be overweight compared to children who did not consume desserts (95% CI=1.19-6.88). Also, childs caloric intake was significantly associated with child WL. Children who consumed more calories were 1.00 times more likely to be overweight compared to children who consumed fewer calories (95% CI=1.00-1.00). DISCUSSION Research on food security and childrens weight has reported mixed findings. Methodological issues have been identified as contributory to the inconsistent findings. Of paramount importance to these studies is the measurement of low food security. CONCLUSION Children in this sample who were food insecure, as indicated by SNAP recipients, were more likely to have a higher WL measurement. Future studies should focus on the correlation between food security and hunger/satiety cues.

A randomized controlled trial to prevent childhood obesity through early childhood feeding and parenting guidance: rationale and design of study

BackgroundEarly and rapid growth in Infants is strongly associated with early development and persistence of obesity in young children. Substantial research has linked child obesity/overweight to increased risks for serious health outcomes, which include adverse physical, psychological, behavioral, or social consequences.Methods/designThe goal of this study is to compare the effectiveness of structured Community Health Worker (CHW)- provided home visits, using an intervention created through community-based participatory research, to standard care received through the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) office visits in preventing the development of overweight (weight/length ≥85th percentile) and obesity (weight/length ≥95th percentile) in infants during their first 3 years of life. One hundred forty pregnant women in their third trimester (30–36 weeks) will be recruited and randomly assigned to the intervention or control group.DiscussionThis study will provide prospective data on the effects of an intervention to prevent childhood obesity in children at high risk for obesity due to ethnicity, income, and maternal body mass index (BMI). It will have wide-ranging applicability and the potential for rapid dissemination through the WIC program, and will demonstrate the effectiveness of a community approach though employing CHWs in preventing obesity during the first 3 years of life. This easy-to-implement obesity prevention intervention can be adapted for many locales and diverse communities and can provide evidence for policy change to influence health throughout life.Trial registrationClinical Trials Number: NCT01905072

Relationship of Sleep Duration and Regularity with Dietary Intake among Preschool-Aged Children with Obesity from Low-Income Families

Objective: Diet is a modifiable factor associated with pediatric obesity outcomes, but few studies have evaluated the relationships of sleep duration and regularity on dietary intake of young preschool-aged children. The goal of this study was to evaluate whether short sleep duration and irregular sleep timing were associated with greater calorie, carbohydrate and fat consumption among young children with obesity from low-income families. Methods: Fifty-one ethnically diverse children aged 2 to 4 years were recruited from the Special Supplemental Nutrition Program for Women, Infants, and Children clinics in a southeast Texas county. Sleep behaviors were parent reported using the Child Sleep Assessment tool. Dietary intake data were obtained by 24-hour recall interviews (2 weekdays and 1 weekend day). Results: Short sleep duration (<11 hr) was highly prevalent among this cohort of preschool-aged children. Short sleep duration was associated with greater fat and decreased carbohydrate consumption. Children with greater variability in sleep duration and timing had greater energy intake from fat and protein sources. Conclusion: Allowing for the opportunity to educate parents on the importance of maintaining regular, adequate sleep and relationships between sleep and dietary intake may decrease the risk of childhood obesity in this high-risk pediatric population.

How Did They Grow: An Intervention to Reduce Stunted Growth in Low-Income Mexican-American Children.

Growth stunting is a complex phenomenon related to undernutrition that can contribute to developmental delay, cognitive deficits, and small size and obesity in adulthood. Stunted growth, defined as height for age below the 5th percentile, is primarily caused by chronic malnutrition. In this study, a community-based intervention to reduce undernutrition was tested in a quasi-experimental design with 174 low-income, Mexican-American mothers and children recruited from a Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinic in a major southwestern city. The intervention was based on the public health nursing practice of collaborating with mothers of young children on appropriate nutrition and parenting, and was tailored by the author and community informants for mothers of children with stunted growth. Data were collected on child height and weight, dietary intake, maternal acculturation, maternal perceived stress as measured by the Perceived Stress Scale (PSS), home environment as measured by the home screening questionnaire (HSQ), and maternal-child interaction as measured by the Nursing Child Assessment Teaching Scale (NCATS). Intervention children had higher growth velocity than the children in the comparison group. These findings were especially prominent for children of women who were older and less acculturated. Results suggest that a nursing intervention delivered in collaboration with WIC can make a significant improvement in growth of low-income children with growth stunting.

Acculturation, Cultural Values, and Breastfeeding in Overweight or Obese, Low-Income, Hispanic Women at 1 Month Postpartum:

Background: Most Hispanic infants are fed formula during the first 6 weeks, and although 80% of Hispanic women initiate breastfeeding, rates of exclusive breastfeeding are much lower. Research aim: The purpose was to examine the influence of acculturation and cultural values on the breastfeeding practices of pregnant women of Mexican descent participating in the Special Supplemental Nutrition Program for Women, Infants, and Children who were enrolled in a prospective randomized clinical trial that aimed to reduce child obesity. The data were abstracted from a larger randomized clinical trial focused on prevention of child obesity. Methods: The sample consisted of 150 women of Mexican origin who were enrolled at the time of these analyses from the randomized clinical trial and had a prepregnancy body mass index of ≥ 25 and spoke English and/or Spanish. All breastfeeding data for this report came from data collection at 1 month postpartum. Results: A higher score on the Anglo orientation scale of the Acculturation Rating Scale for Mexican Americans was associated with less breastfeeding at 1 month postpartum and less exclusive breastfeeding. Conclusion: Acculturation plays a role in breastfeeding practice. Exploring acculturation associated with breastfeeding can guide us to design culturally relevant interventions to promote breastfeeding exclusivity among immigrant mothers.

The Role of SNAP in Home Food Availability and Dietary Intake among WIC Participants Facing Unstable Housing

Objective: Little nutrition research has been conducted among families with unstable housing. The objective of this study was to examine the role of food stamps (i.e., Supplemental Nutrition Assistance Program; SNAP) in home food availability and dietary intake among WIC families who experienced unstable housing. Design and Sample: Cross‐sectional study among vulnerable families. Low‐income, multiethnic families with children participating in WIC (n = 54). Measures: Dietary intake was assessed with 24‐hr recalls. Home food availability was assessed with an adapted home food inventory for low‐income, multiethnic families. Validation results from adapted home food inventory for these families are also reported. Results: SNAP households had more foods than non‐SNAP households; few significant associations were observed between food availability and child dietary intake. Conclusions: With few exceptions, the home food environment was not related to childrens dietary intake among these vulnerable families. More research is needed on food access for families facing unstable housing.

Randomized Controlled Trial to Prevent Infant Overweight in a High-Risk Population

OBJECTIVES Infants are at risk of overweight. Infant overweight predisposes child, adolescent, and adult to obesity. We hypothesized that parent education, initiated prenatally and provided in the home, would reduce the incidence of infant overweight at age 12 months. METHODS Pregnant obese Latina women were recruited at Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and randomized to intervention versus control. Intervention subjects received home visits by trained Spanish-fluent community health workers who provided counseling on infant growth, breastfeeding, nutrition, child development, sleep, physical activity, and safety. Promotoras did not visit the control subjects. A research assistant collected outcome data on all subjects. RESULTS Compared to controls, parent education did not reduce infant overweight. Infant overweight developed rapidly and was present in 46% of infants by age 6 months. Infants overweight at 6 months were likely to be overweight at age 12 months (r = 0.60, P < .0001). Overweight was more common in formula-fed infants at ages 6 months (P < .06) and 12 months (P = .005). Breastfeeding was less common in families with employed mothers (P = .02) and unemployed fathers (P < .01), but the father living with the mother at the time of the prenatal visit predicted successful breastfeeding at infant age 2 months (P < .003). Compared to formula feeding, overweight at age 12 months was 2.7 times less likely for infants breastfed for ≥2 months (P = .01). CONCLUSIONS The lack of success of the intervention may be explained in part by a high cesarean section rate in the intervention group, food and employment insecurity, and confounding by WIC breastfeeding promotion, which was available to all mothers. Breastfeeding was the most important mediator of infant overweight. The study supports efforts by WIC to vigorously promote breastfeeding.