Running head: TODDLER OBESITY 1

Effects of Breastfeeding on Toddler Obesity

Kaelyn Snyder, Mara McCauley, Cassandra LaRose, Alexis Desantis

April 7, 2018

NURS 3947: Nursing Research

Dr. Patricia Hoyson & Dr. Mary Shortreed

TODDLER OBESITY 2

Abstract

The purpose of this research was to look at the relationship between breastfeeding and toddler

obesity. This research examined the correlation of introducing solid foods earlier versus con-

tinuing breastfeeding until a later age. It also examined satiety cues related to overfeeding, as

well as parenting styles and dietary macronutrient intake. The evidence gathered in this essay

was form eight different research studies. It was found that there is significant evidence to

prove that introducing solid foods earlier in a child’s life increases the chances of obesity ra-

ther than continuing breastfeeding for a longer period of time. It was also found that permis-

sive parenting positively correlated with total calorie, fat, and carbohydrate intake in toddlers.

Overall, introducing solid foods before six months of age, permissively parenting, and discon-

tinuing breastfeeding before six months of age impacts toddler BMI and the prevalence of obe-

sity in toddlers.
TODDLER OBESITY 3

Any working nurse has encountered a patient living with or suffering from strokes, type

two diabetes, coronary artery disease, or cancer. One of the biggest factors attributed to devel-

oping the aforementioned health issues is obesity. According to the Centers for Disease Con-

trol (2018), the United States in 2008 alone spent 147 billion dollars on the medical treatment

associated with obesity, and more than 36% of the country’s adult population is considered

obese. This means over one third of adults have a Body Mass Index (BMI) over 30. These sta-

tistics leave the nation wondering how those results got out of hand and became so high. The

development of toddler and childhood obesity is greatly responsible for a majority obesity in

adults. With the nurse to patient ratios widening, reducing the instance of obesity will have an

effect on lowering the rates of the above disease processes, thereby decreasing that ever-so-ele-

vating patient load. That being said, patient education is one of a nurses strongest weapons in

their arsenal; however, toddlers are not the primary individual involved in their decision mak-

ing, so the responsibility to ascertain the necessary education extends to their parents and care-

givers. This left many researchers with the question that sparked the research in this report.

What effects does breastfeeding have on toddler obesity in the United States?

A group of researchers from the Center for Health Research wondered the same thing.

Knowing that one of the many factors that put children at risk for developing obesity is race,

the researchers focused on the minority of American Indian (AI) children. As of 2013, 40% of

AI preschool aged children already struggle with being overweight and obese, and AI infants

gain weight more rapidly in their first six months of life than any other race. The research

question in this study asked if obesity prevention beginning at birth would reduce the fre-

quency of overweight children at age two. They performed a study called the Prevention of

Toddler Obesity & Teeth Health Study, or PTOTS, for short. The intervention took place by
TODDLER OBESITY 4

targeting expectant mothers and educating them on four different topics: promotion of breast-

feeding, reduction of sugar-sweetened beverage consumption, timing of introduction to solid

foods, and reduction of sedentary lifestyle.

A big problem with their ability to carry out this research was that very little had been

done prior. This is because preventing obesity in infants under one year of age improperly may

lead to a failure to thrive. They ensured the participants that infants would be at no harm and

not conflict with aspects of proper child health and development. Five tribes were set to partic-

ipate—three as intervention groups and two as comparison groups. After parent education was

provided, BMI’s were measured every six months until age two. Out of four concepts taught

upon, only one led inconclusive results. Research has not proven or disproven that properly

timing the introduction of solids will have an effect on BMI. The other three components, how-

ever, did have data to attest to their contribution to decreased instances of obesity in toddlers.

Comparatively, the study of Association of Infant Feeding and Dietary Intake on Obe-

sity Prevalence in Low-Income Toddlers looked at the prevalence of obesity in low-income

families related to breastfeeding and dietary intake, such as sugar-sweetened beverages (SSB)

(Davis, Koleilat, Shearrer, & Whaley, 2014). This study examined 2,295 toddlers aged two to

four, and these families were primarily Hispanic who were receiving Women, Infants, and

Children (WIC) benefits. It was found that, “High intake of soda, diet soda, and fruit drinks

were linked to increases in obesity prevalence. There was no effect of 100% juice, milk (plain

or flavored), fruit, vegetable, fast food, or sweetened grain intake on obesity preva-

lence…These findings support encouragement of breastfeeding [for] 12 months and no SSB

intake to prevent obesity in low-income, primarily Hispanic, toddlers” (Davis et al., 2014).

Overall, it is recommended for parents to continue breastfeeding for up to a year, to have diets
TODDLER OBESITY 5

that consist of low sugar, low fat, and high in fiber diets, and not to introduce SSB to their chil-

dren at all due to the risk of obesity—especially Hispanic families.

Another group of researchers from the Department of Pediatrics at Duke University or-

ganized a similar study, but this time on childbearing women who were overweight or obese

themselves. Their research focused solely on the effect breastfeeding would have on these

women's children’s satiety response, or the body’s response to the feeling of fullness that sig-

nals them to stop eating. After analyzing data on 428 toddlers aged two years old, they con-

cluded that they could not make a connection to being breastfed as an infant affecting this sa-

tiety response. What they did find, however, was that the more intense a mother’s breastfeed-

ing habits were, the lower the odds would be of the child becoming either obese or overweight.

Although this concept was not their main purpose of the study, the results came back so

strongly suggesting the correlation between breastfeeding and toddler obesity, that their confi-

dence interval was stated to be 95%. This study just further proves that infants who are formula

fed have an increased likelihood of developing obesity as the age and develop.

Ehrenthal, Wu, & Trabulsi (2016) conducted a study to examine the relationship be-

tween the infant was fed and how that corresponds for that child to be at risk for becoming

overweight and obese throughout their early lifespan. The sample of mothers were drawn from

the Delaware Mother Baby Cohort (DMBC), and after eliminating some children, the sample

the study was left with consisted of 2,172 mother-infant dyads. The study included data ob-

tained from electronic medical records. The records showed whether the infant was exclusively

breastfed, exclusively bottle fed, or mixed feeding, and used height and weight to calculate the

child’s BMI. The BMI was measured at the child’s well-child visit at six months and four years

of age, where the study would use the data to find out whether the child was of normal weight
TODDLER OBESITY 6

for age, overweight for age, or obese for their age. The results ended up showing that, “when

compared to children who had been exclusively breastfed, those who were exclusively for-

mula-fed or received mixed feeding had a higher BMI Z-score and there was no significant dif-

ference in BMI Z-score between those exclusively formula-fed or received mixed feeding at

age 4,” (Ehrenthal et al., 2016). Due to these findings, the researched put the children who

were exclusively formula-fed and those who had mixed feedings into one group, and had ex-

clusive breastfeeding as a separate group.

Overall, the conclusion of this research study found that those children who were exclu-

sively formula-fed or had a mixed feeding as an infant at two months of age were discovered to

have a higher BMI Z-score at four years of age than those infants who had been exclusively

breastfed. In the Ehrenthal et al. (2016) study, it was decided that, “policies and programs to

promote the initiation and duration of breastfeeding globally are essential,” to make people

aware of the correlation between exclusive formula-fed and mixed fed infants, and childhood

obesity. The prevention of childhood obesity needs to start with education for the mothers.

Moss & Yeaton (2014) created a study in order to find a relationship between breast-

feeding and postponing the introduction of solid foods in children at two and four years of age.

After eliminations were made for various reasons the study had around 6,950 children at the

four year mark. The children were first classified into two groups, whether they were breast

fed, or not. They were then categorized into three groups. The first group was introduced to

solid foods at less than four months, the second group was introduced to solid foods between

four and five months, and the third group at six months or longer. The results of the study were

based on the relationship between feeding practices and the child’s weight status, which was

recorded using the CDC’s reference growth chart for accuracy. The findings found that when
TODDLER OBESITY 7

children were breast fed, at two and four years they were more likely to have a healthy weight

status and lower obesity incidence compared to children that were never breastfed. It was also

found that when children were introduced solid foods before four months of age, their obesity

rates at two and four years of age was higher than children who were delayed solid food intro-

duction. The study found that, “regardless of timing of SF, breastfed children had lower odds

of obesity when compared to children who were not breastfed (2y OR: 0.64 vs. 1.00 (reference

group) for 4 months; 0.38 vs. 0.67 for 4–5 months; OR: 0.38 vs. 0.69 for C6 months; and 4

year OR: 4 year OR: 0.72 vs. 1.00 (reference group) for 4 months; 0.45 vs. 0.66 for 4–5

months; OR: 0.51 vs. 0.68 for C6 months),” (Moss & Yeaton, 2014). Overall, it is very im-

portant for children to be breastfed until the age of one, and delayed solid food introduction

until at least six months of age as recommended by the AAP. This will only help decrease the

odds of toddler obesity and provide better health outcomes for their future.

A rather alarming statistic discovered by The Feeding Infants and Toddler Study (FITS)

was that,

…data on the dietary patterns of 3022 infants and toddlers, revealed that 4 to 24 month

old children typically consumed significant amounts of developmentally inappropriate,

energy-dense, nutrient poor foods. Of particular concern was the finding that 18% to

33% of infants and toddlers consumed no distinct servings of vegetables on a typical

day and when vegetables were consumed the most common choice was french fries.

Additionally, reported energy intakes exceeded requirements by 10 to 30%. (Birch,

Savage, & Ventura, 2007).

This is an important finding because it raises a flag that parents are a huge factor in the infants

eating habits. Mothers also need to eat healthy in order to set a good example and promote a
TODDLER OBESITY 8

healthy weight status for their children as they transition from infancy to toddlerhood espe-

cially while breastfeeding. Due to the fact that infants are born with a preference for sweet and

salty taste, they are less likely to accept bitter tasting things such as vegetables. With that being

said, what the mother eats while nursing is extremely important in order to promote the infants

acceptance of similar flavored solid foods and help the infant make healthy choices while tran-

sitioning into toddlerhood to prevent obesity. While Moss’s study found the importance of

breastfeeding and the delay of solid food introduction, Birch’s study was able to elaborate and

show the importance of what foods are introduced when solid foods are finally given.

Mustila, Raitanen, Keskinen, Saari, & Luoto (2013) found that the start of obesity is di-

rectly connect to early life. These researchers decided that, “preventive efforts should start in

early life. Pragmatic trials are needed to find an effective preventive program that is applicable

in existing health care settings.” The sample group of this study was as follows: the interven-

tion group consisted of children born to mothers in 2009 and 2010, and the control group was

recruited among mothers who had undergone OGTT in mid-pregnancy because of a risk of

GDM (Mustila et al., 2013). It is known that children start to accept certain preferences for

taste during early life by tasting breast milk. It was also shown throughout the study that

breastfeeding that was recommended by health care providers until up to six months of age so

that the infant would gain weight adequately and in a healthy manner.

As a final result, this study found that exclusive breastfeeding for multiple months did

not have a significant difference than those infants who were not exclusively breastfed. It did

not specifically say how many months each of these mothers breastfed for, but that the amount

of time each infant was breastfed for were similar in both groups. Overall, this study ended up

not intervening much in the topic of breastfeeding. It was said that due to the similar weight
TODDLER OBESITY 9

gain of both the intervention and control group, that breastfeeding had no positive or negative

effect the child’s chances of becoming overweight or obese later on in life.

Toddler obesity is on the rise causing many childhood psychological and physiological

issues, and also long term adult adverse health conditions. So, in order to help prevent toddler

obesity and maintain a healthy weight status, the Academy of Pediatrics (AAP) advises parents

to exclusively breastfeed their infant until six months of age, and postpone the introduction of

solid foods until after six months of age (Moss & Yeaton, 2014). It is also recommended to

continue breastfeeding until one year of age after nutritious solid foods have been introduced

to the infant. A rather common problem that is occurring as well, is that when infants are intro-

duced to foods they are generally developmentally inappropriate, energy dense, nutrient poor

foods (Birch et al., 2007).

Along with comparing when to introduce solid foods and early discontinuation of

breastfeeding, parenting styles were also examined with their relationship with toddler obesity

and BMI. In the study of The Relationship Between Parenting Styles, Dietary Macronutrient

Intake, and BMI in Toddlers, 47 mother-toddler pairs, with toddlers from ages 2.5 to four years

of age were examined. A 24-hour recall on the toddlers diet was assessed, as well as the tod-

dler’s anthropometrics. Parenting styles were assessed through a questionnaire, resulting in au-

thoritative, authoritarian, permissive, and neglectful. In this study, all mothers were married

and all racial and ethnic differences were included. It was found that there is a significant posi-

tive correlation between permissive parenting styles and what toddlers are eating, and permis-

sive parenting—not maternal BMI—is a predictor of toddler BMI (Crutchfield, 2015). One of

the limitations of this study would be that there is a need for more research on toddlers this age

and a larger population to look at. Also, when determining a larger population, what should be
TODDLER OBESITY 10

considered is single parents versus married to determine if there would be disparities in the re-

sults.

Overall, there was significant evidence to prove that introduction of solid foods to in-

fants before six months of age increases the toddler’s risk for being overweight or obese, and

breastfeeding an infant until one year of age to reduce their risk even further. It was also found

that introducing SSB to toddlers increases the risks of obesity as well. Children who were

strictly formula fed or had mixed feeding of formula and breast milk, still had higher BMI’s

than those who were strictly breastfed. It is apparent that even well-educated mothers need

more information regarding the nutrient intake of their children and the importance of a fully

balanced diet. If well-educated mothers are not fully educated on their child’s diet, one can

only imaging the knowledge deficit of a younger woman less educated. This teaching interven-

tion can be done by the postpartum nurse in the hospital before the mother leaves with her

baby. If a nurse or doctor were to give mothers further teaching about the importance of breast-

feeding and obesity in this country, it would be interesting to see if the prevalence of obesity

would finally decrease in the United States.

TODDLER OBESITY 11

References

Birch, L., Savage, J. S., & Ventura, A. (2007). Influences on the development of children's eat-

ing behaviours: From infancy to adolescence. Canadian Journal of Dietetic Practice

and Research, 68(1), S1-S5. Retrieved from https://search-proquest-com.proxy.ohio-

link.edu:9100/docview/220823425?accountid=12953

Centers for Disease Control and Prevention. (2018). Adult obesity facts. Obesity & Over-

weight. Retrieved from https://www.cdc.gov/obesity/data/adult.html

Crutchfield, M. (2015). The relationship between parenting styles, dietary macronutrient in-

take, and BMI in toddlers. Available from Nursing & Allied Health Database.

(1819397244). Retrieved from https://search-proquest-com.proxy.ohi-

olink.edu:9100/docview/1819397244?accountid=12953

Davis, J. N., Koleilat, M., Shearrer, G. E., & Whaley, S. E. (2014). Association of infant feed-

ing and dietary intake on obesity prevalence in low-income toddlers. Obesity, 22(4),

1103-1111. doi:10.1002/oby.20644

Ehrenthal, D. B., Wu, P., & Trabulsi, J. (2016). Differences in the protective effect of exclu-

sive breastfeeding on child overweight and obesity by mother's race. Maternal and
TODDLER OBESITY 12

Child Health Journal, 20(9), 1971-1979.

doi:http://dx.doi.org.proxy.ohiolink.edu:9099/10.1007/s10995-016-2015-z

Hathcock, A., Krause, K., Viera, A. J., Fuemmeler, B. F., Lovelady, C., & Østbye, T. (2014).

Satiety responsiveness and the relationship between breastfeeding and weight status of

toddlers of overweight and obese women. Maternal and Child Health Journal, 18(4),

1023-30. doi:http://dx.doi.org.proxy.ohiolink.edu:9099/10.1007/s10995-013-1331-9

Karanja, N., Aickin, M., Lutz, T., Mist, S., Jobe, J. B., Maupomé, G., & Ritenbaugh, C.

(2012). A community-based intervention to prevent obesity beginning at birth among

american indian children: Study design and rationale for the PTOTS study. Journal of

Primary Prevention, 33(4), 161-74. doi:http://dx.doi.org.proxy.ohi-

olink.edu:9099/10.1007/s10935-012-0278-8

Moss, B. G., & Yeaton, W. H. (2014). Early childhood healthy and obese weight status: Poten-

tially protective benefits of breastfeeding and delaying solid foods. Maternal and Child

Health Journal, 18(5), 1224-32. doi:http://dx.doi.org.proxy.ohi-

olink.edu:9099/10.1007/s10995-013-1357-z

Mustila, T., Raitanen, J., Keskinen, P., & Luoto, R.(2018). A pragmatic controlled trial to pre-

vent childhood obesity within a risk group at maternity and child health-care clinics:

Results up to six years of age (the VACOPP study). BMC Pediatrics, 18(89), 1-9. doi:

10.1186/s12887-018-1065-3.