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This study examines associations of timing of CF introduction with adiposity throughout abstract
childhood and adolescence in the US Project Viva prospective cohort study.
OBJECTIVES:
To examine associations of the timing of complementary feeding (CF) introduction
with adiposity throughout childhood.
METHODS: We studied 1013 children from Project Viva. Our exposure was CF introduction,
categorized as ,4 months (19%), 4 to ,6 months (68%; reference group), and $6 months of
age (14%). Our outcomes included adiposity measures in midchildhood (mean: 7.9 years; SD
0.8; n = 896) and early adolescence (mean: 13.2 years; SD 0.9; n = 850). We used linear
regression models adjusted for potential confounders and ran separate models for infants
who were breastfed at least partly for $4 months (categorized as breastfed; 69%) and infants
who were never breastfed or stopped breastfeeding at ,4 months (categorized as formula
fed; 31%).
RESULTS: CF initiated at ,4 months was associated with higher adiposity in midchildhood in
breastfed children; associations persisted into adolescence for waist circumference, truncal fat
mass, and the sum of subscapular and triceps skinfolds (eg, waist circumference: confounder-
adjusted b 2.97 [95% confidence interval (CI) 0.47 to 5.47] cm). The effect estimates were
larger in formula-fed children, with more associations persisting into adolescence (eg, waist
circumference: adjusted b 3.42 [95% CI 0.12 to 6.71] cm). CF initiated at $6 months was
associated with a higher subscapular/triceps skinfold ratio in midchildhood and adolescence
(adjusted b 0.13 [95% CI 0.02 to 0.25]) in formula-fed children.
CONCLUSIONS:
We found associations of early CF introduction with higher adiposity
measurements in breastfed and formula-fed children and associations of late introduction of
CF with higher adiposity in formula-fed children.
a
Department of Nutrition, Harvard T.H. Chan School of Public Health and bDivision of Chronic Disease Research WHAT’S KNOWN ON THIS SUBJECT: The timing of complementary
Across the Lifecourse, Department of Population Medicine, Harvard Medical School, Harvard University and feeding (CF) introduction could possibly contribute to childhood
Harvard Pilgrim Health Care Institute, Boston, Massachusetts; cDepartment of Obstetrics and Gynecology, Yong obesity, although the evidence is inconsistent. Previous findings
Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; dSingapore Institute for suggest that early introduction of complementary foods might be
Clinical Sciences, Agency for Science, Technology, and Research, Singapore, Singapore; and eDiabetes Unit, associated with an increased risk of obesity in early childhood.
Massachusetts General Hospital, Boston, Massachusetts
WHAT THIS STUDY ADDS: CF introduction at ,4 months was
Dr Gingras designed the analysis, conducted the initial analyses, drafted the initial manuscript, and associated with higher adiposity measurements in midchildhood
reviewed and revised the manuscript; Dr Aris contributed to data analysis and critically reviewed and adolescence. CF introduction at $6 months was associated
the manuscript for important intellectual content; Ms Rifas-Shiman reviewed the study design, with higher adiposity through adolescence in children who were
contributed to statistical analyses, and critically reviewed the manuscript for important intellectual never breastfed or stopped breastfeeding at ,4 months only.
content; Dr Switkowski reviewed the study design and critically reviewed the manuscript for
important intellectual content; Dr Oken obtained funding for the study, oversaw data collection, To cite: Gingras V, Aris IM, Rifas-Shiman SL, et al. Timing
reviewed the study design, and critically reviewed the manuscript for important intellectual of Complementary Feeding Introduction and Adiposity
content; (Continued) Throughout Childhood. Pediatrics. 2019;144(6):e20191320
as well as with a higher skinfold ratio $6 months also seemed to be vegetables, and 30% were given fruit
in early adolescence (model 1; age associated with other adiposity juice. In breastfed children, early
and sex adjusted); however, the effect measures with estimated effect sizes introduction of infant cereals and
estimates were moderately similar to or greater than what we fruit juice was associated with
attenuated after adjustment for observed for CF introduction at a higher BMI z score and waist
confounders (model 2), with ,4 months in formula-fed children, circumference in midchildhood, and
confidence intervals (CIs) crossing although with wider CIs that did not the association for infant cereals and
the null. No associations were found exclude the null (Table 2). waist circumference persisted in
for CF introduction at $6 months and early adolescence. In formula-fed
adiposity in breastfed children In exploratory analyses, we also children, early introduction of infant
(Table 2). examined associations of the timing cereals was associated with a higher
of introduction of specific food items BMI z score in midchildhood and
In formula-fed children, CF and offspring’s BMI z score and waist early adolescence and with higher
introduction at ,4 months was circumference. The specific food waist circumference in midchildhood
associated with a higher BMI z score, items introduced more commonly (Table 4).
waist circumference, DXA truncal fat before 4 months were infant cereals
mass, sum of skinfolds, and skinfold (15% of children), fruits (6%),
ratio in midchildhood (model 2; vegetables (4%), and fruit juice (6%; DISCUSSION
adjusted for confounders). Effect Table 3). Although most children In this prospective longitudinal
estimates for these associations were were introduced to CF at ,6 months cohort, we found associations of the
similar or larger in early adolescence (86%), meat, soy and cow’s milk, timing of CF introduction with child
(model 2; adjusted for confounders). dairy, peanut butter, eggs, fish, and adiposity throughout childhood and
Also, CF introduction at $6 months sweets were introduced in ,10% of early adolescence. Sociodemographic
was associated with a higher skinfold children at ,6 months. Among characteristics as well as
ratio in midchildhood and early children introduced to CF at ,4 breastfeeding status were associated
adolescence in fully adjusted models. months, 82% were fed infant cereals, with the timing of CF introduction. In
In this group, CF introduction at 30% were fed fruits, 22% were fed breastfed children, early CF
introduction was associated with early CF introduction was associated $6 months was associated with
higher adiposity measurements with higher adiposity measurements a higher skinfold ratio in
throughout childhood and early throughout childhood and early midchildhood and early adolescence.
adolescence. In formula-fed children, adolescence, and CF introduction at Associations were stronger and more
Breastfed children
Midchildhood
BMI, z score 0.28 (0.03 to 0.53) 0.0 20.08 (20.26 to 0.22 (20.17 to 0.61) 0.0 20.08 (20.23 to 0.30 (20.15 to 0.75) 0.0 20.08 (20.22 to 0.46 (0.04 to 0.88) 0.0 0.03 (20.14 to 0.21)
(reference) 0.11) (reference) 0.06) (reference) 0.06) (reference)
Waist circumference, cm 2.24 (0.46 to 4.01) 0.0 0.12 (21.18 to 1.42) 0.87 (21.89 to 3.64) 0.0 0.24 (20.78 to 1.26) 0.75 (22.45 to 3.96) 0.0 0.06 (20.94 to 1.06) 3.44 (0.48 to 6.40) 0.0 0.10 (21.14 to 1.35)
(reference) (reference) (reference) (reference)
Early adolescence
BMI, z score 0.20 (20.08 to 0.0 20.04 (20.24 to 0.27 (20.15 to 0.69) 0.0 0.06 (20.10 to 0.22) 0.34 (20.16 to 0.84) 0.0 0.08 (20.08 to 0.23) 0.21 (20.24 to 0.67) 0.0 0.03 (20.16 to 0.22)
0.47) (reference) 0.16) (reference) (reference) (reference)
Waist circumference, cm 3.02 (0.21 to 5.82) 0.0 0.67 (21.35 to 2.68) 3.72 (20.56 to 8.00) 0.0 1.03 (20.57 to 2.64) 4.17 (20.96 to 9.30) 0.0 0.84 (20.75 to 2.42) 2.71 (21.93 to 7.35) 0.0 20.00 (21.96 to 1.96)
Adjusted for child age at outcome assessment and sex (except for BMI z score), maternal education, marital status, household income, maternal prepregnancy BMI, paternal BMI, child’s race and/or ethnicity, infant gestational age at delivery, and
change in wt-for-age z score from 0 to 4 mo.
introduction.
comprehensive guidance on CF
However, early CF introduction
7
only when CF is introduced and what
available to guide the type of foods to
introduction is an indicator of greater
primarily involved the introduction of
Dr Hivert codesigned the analysis and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as
submitted and agree to be accountable for all aspects of the work.
This trial has been registered at www.clinicaltrials.gov (identifier NCT02820402).
DOI: https://doi.org/10.1542/peds.2019-1320
Accepted for publication Sep 17, 2019
Address correspondence to Véronique Gingras, RD, PhD, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute,
Landmark Center, 401 Park Dr, Suite 401 East, Boston, MA 02215. E-mail: veronique_gingras@harvardpilgrim.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2019 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by the US National Institutes of Health (grants R01 HD 034568 and UG3 OD023286). Dr Gingras is supported by a postdoctoral fellowship award
from the Canadian Institutes of Health Research. Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
REFERENCES
1. Fryar CD, Carroll MD, Ogden CL. 4. Woo Baidal JA, Locks LM, Cheng ER, 7. Schack-Nielsen L, Sørensen TI,
Prevalence of overweight and obesity et al. Risk factors for childhood obesity Mortensen EL, Michaelsen KF. Late
among children and adolescents aged in the first 1,000 days: a systematic introduction of complementary feeding,
2-19 years: United States, 1963-1965 review. Am J Prev Med. 2016;50(6): rather than duration of breastfeeding,
through 2013-2014. 2016. Available at: 761–779 may protect against adult overweight.
www.cdc.gov/nchs/data/hestat/ Am J Clin Nutr. 2010;91(3):619–627
5. Papoutsou S, Savva SC, Hunsberger M,
obesity_child_13_14/obesity_child_13_
et al; IDEFICS Consortium. Timing of 8. Fall CH, Borja JB, Osmond C, et al;
14.htm. Accessed May 2018
solid food introduction and association COHORTS Group. Infant-feeding patterns
2. Ogden CL, Carroll MD, Fryar CD, Flegal with later childhood overweight and and cardiovascular risk factors in young
KM. Prevalence of obesity among adults obesity: the IDEFICS study. Matern Child adulthood: data from five cohorts in low-
and youth: United States, 2011-2014. Nutr. 2018;14(1):e12471 and middle-income countries. Int
NCHS Data Brief. 2015;(219):1–8 J Epidemiol. 2011;40(1):47–62
6. Seach KA, Dharmage SC, Lowe AJ, Dixon
3. Gingras V, Hivert MF, Oken E. Early-life JB. Delayed introduction of solid 9. World Health Organization; United
exposures and risk of diabetes feeding reduces child overweight and Nations Children’s Fund. Global Strategy
mellitus and obesity. Curr Diab Rep. obesity at 10 years. Int J Obes. 2010; for Infant and Young Child Feeding.
2018;18(10):89 34(10):1475–1479 Geneva, Switzerland: World Health
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