Evidence-Based Nursing Research Project Paper

Gillian Davis, Laura Evans, Rachael Griffith, Lydia Kranz, Miranda Woodson, Katie Wright
Group 5

1. Table of Evidence

Does breastfeeding in infancy reduce the future risk of Type II diabetes as compared to bottlefeeding?

2. Synthesis
Rothfus (2012) writes about the Breast vs. Bottle Battle in summary throughout the
decades and fads in the U.S. regarding how to feed an infant during the first year of life. Some
of the battle has to deal with who is presenting the information: science, government, or
businesses. There is not much unbiased opinion in the world when this issue arises. As the
battle between breast and bottle continues, mothers in the world will not actually know what is
best for the health and development of her child due to the opposing opinions of science, the
government, as well as businesses. When a woman has a child, one of the first instincts of that
woman may to be talk with her mother about how she cared for her children (Rothfus, 2012).
This may also skew the opinions of todays mothers because fads have come and gone,
opinions have swayed back and forth, evidence and science has not been broadcasted neutrally
for the worlds mothers to observe and research. Aggressive marketing and faux research are
reasons why there is still a battle over breast vs. bottle feedings. Although this article was less of
a study and more of a summary, an important topic was brought to the publics attention: there
needs to be more evident research that is presented neutrally or unbiased so mothers can
decide for themselves how to feed, care, and nurture each child for growth and development.
In Breast-Feeding and Risk for Childhood Obesity, a study found that breastfeeding,
overall, is associated with reduced weight in young childhood. This would prove to the reader
that if a mother is able to breastfeed, it should be done in order to avoid childhood obesity which
can predispose a child to other ailments of illness. Many children were involved within this study,
yet the distribution of social, race, ethnicity, income, and types of parenting were not accounted
for or diverse. In order to validate the research done, it is important that more than only healthy
mothers living easily with a steady income in a healthy environment are included in the studies.

Although the validity and diversity of this study is not sufficient, the findings of the research did
aid in the progression of other studies. It was found, through the longitudinal studies of the
children who were breast vs. bottle fed, that the prevalence of overweight youth was reduced as
the prevalence of breastfeeding was prominent within the first full year of a childs life (MeyerDavis et. al, 2232).
Breast Feeding: preventive therapy for type two diabetes found breastfeeding to be a
preventive factor of metabolic syndrome in both mothers and their children. This evidence is
based off the physiological mechanisms of breast milk and its ability to improve metabolism
through lactogenesis, prolactin, and lactation (Karla et al, 2015). There was no specific group
being studied, rather this article reviewed previous studies which had been completed, which
allows commonalities between studies to be shown. With this being said, there needs to be
more evidence based research using diverse mothers and infants to increase validity. This
article shows great differences from other studies because it includes ways to encourage
breastfeeding and lactation rather than just stating it should be done.
Early-life influences on obesity: from preconception to adolescence, published by The
Annals of the New York Academy of Sciences published, is a systematic review article which
together experts from different health care to determine what are the causes of obesity and
other disease associated with obesity such as chronic illnesses and diabetes (Wahlqvist et al,,
2015). This article reviewed other studies which included surveys, growth charts, bmi scales,
maternal income, and maternal age to research causes of obesity in late
childhood/adolescence. The review did not find a particular feeding style was associated with
overweight/diabetic styles. However, they did find human milk has a component that may
increase lean body mass and aide in adipogenesis, which has also been found in many other
studies. The difference with this review is the comprehensiveness, which ended up involving
over 10,000 families in total. . Limitations include any limitations which were noted in the studies
being reviewed. Many articles which were reviewed were opinion based rather than evidence
based, which lessens the validity.
In a study by Mamun et al. (2015), the length of breastfeeding of an infant was
compared to the development of diabetes during childhood. A sample of 3,595 offspring
between 1981 and 1983 were selected in Brisbane, Australia for the study. These children were
followed for their first twenty-one years of life and doctor-diagnosed diabetes were reported as
well as the mothers lengths of breastfeeding for each child. The study showed that infants who
were breastfed for four months or longer had decreased rates of diabetes, revealing
breastfeeding to be a protective factor against diabetes. This study did have some limitations
including not distinguishing between mothers who breastfed full time and those who were only
partially breastfeeding and the difference between type I and type II diabetes. These limitations
could have affected the ultimate results of the study. The rates of breastfeeding found in this
study were consistent with other studies according to the article (Mamun et al., 2015). Other
studies used in this project focused mainly on type II diabetes, while the study by Mamun et al.
(2015) did not distinguish between types, so it may not be as reliable.

In an article by Pereira, Alfenas, and Araujo (2014), the importance of breastfeeding

related to the development of diabetes later in childhood was investigated. This study reviewed
twenty-one articles on the subject to assess links and overall outcomes. Factors such as
duration and exclusivity of breastfeeding were gauged and linked to the rate of type I and type II
diabetes in childhood. Pereira et al. (2014) found that lack of breastfeeding could be a potential
modifiable risk factor for both types of diabetes in children, although no consensus could be
concretely found in the review of the studies.. The study postulated that perhaps well-designed
longitudinal studies are needed to get a better picture of the topic at hand (Pereira et al., 2014,
p. 14). One limitation listed by the authors was small sample size, which could be fixed in future
studies by expanding their samples and looking at a longer amount of time.
In the article Babytalk, Breast Vs. Bottle poll by Tusa et al (2001), medical
professionals discuss how there is a bias and that many mothers feel that just breastfeeding
their baby exclusively is shortchanging to their infant and that a combination of the two methods
is best when it comes to nourishment and developmental growth later on in life. In the data, it
also shows that there is a trend where mothers who exclusively breast fed felt that moms who
exclusively formula fed their babies are shortchanging them as well (2001). Another point
brought up in the study is that according to the poll, mothers who exclusively formula feed do
feel as though they are being criticized by breast feeders, but rather that breast feeders simply
have a sense of self righteousness (2001) about them. The social correlation between
knowledge about the two methods versus what mothers think they should or should not do is
explained in this poll and is important to keep in mind when looking at the social and
psychological implications of determining whether or not to breastfeed. This stigma could sway
a mother one way or another and make her not choose what method is best for her and her
infant best interest and health, but rather based on what society thinks.
In the article Beneficial effects of breastfeeding in Women with Gestational Diabetes
Mellitus by Much et al (2014), the correlation between breastfeeding and women who have
gestational diabetes is discussed in regards to the benefits seeing as women who have
gestational diabetes are at a higher risk of developing type 2 diabetes mellitus later on in life.
Researchers discuss how there is growing evidence to suggest that breastfeeding has both
short term and long term benefits for women with gestational diabetes. According to the article
Mothers with GDM who breastfeed have improved lipid and glucose metabolic profiles for the
first 3 months after birth. However, women with GDM are less likely to breastfeed and, if they
do, breastfeeding is usually continued for a shorter duration compared with women without
GDM (2014). There was also a study done that followed women with gestational diabetes up
to 19 years postpartum and found that those who breastfed greater than 3 months had a lower
incidence of type 2 diabetes later in life (2014). This article gives great insight into exactly how
breastfeeding correlated with type 2 diabetes in the human body. This information could then
possibly show a correlation between breastfeeding and the incidence of diabetes in children in
that it lowers the risk of development.
In the article Long-term consequences of breastfeeding on cholesterol, obesity, systolic
blood pressure and type 2 diabetes: a systematic review and meta-analysis, Horta et al. (2015)

aimed to review the evidence of a correlation between breastfeeding and overweight/obesity,

blood pressure, total cholesterol, and type 2 diabetes. This study is a systematic review and
meta-analysis and therefore has level 1 evidence towards its findings. Four databases were
searched for both observational and randomized studies that researched the long-term effects
of breastfeeding from September 2011 to August 2014. Studies involved children 1 years of age
and older, including adolescents and adults. Studies that were restricted to infants were
excluded. A strength of this study was that it reviewed high-quality studies from both highincome and low- or middle-income settings. A weakness in this study was that it is prone to
publication bias. Among the four consequences observed, obesity and type 2 diabetes were
consistently associated with breastfeeding, where breastfeeding was found to have a 13%
reduction in overweight/obesity and the odds of having type 2 diabetes were decreased (Horta
et. al, 2015). This study shows that breastfeeding a child may reduce the later risk of that child
becoming overweight/obese or developing diabetes. A larger pool of studies which adjust for
socio-economic and birth weight variables would be valuable to future studies on this topic.
In the article Determinants of blood glucose and insulin in healthy 9-month-old term
Danish infants; the SKOT cohort, Madsen et. al (2010) sought to examine insulin concentration
in relation to breastfeeding practice. This cross-sectional study was part of an ongoing
prospective cohort by the SKOT cohort in Denmark, which gives it level 4 evidence. Threehundred and twelve infants aged 9 months were selected from April 2007 to May 2008 by
random selection from the National Danish Civil Registry of infants living in Copenhagen and
Frederiksberg, and the 265 infants that had data on glucose and insulin levels were chosen for
the study. Infants included were those born at or after 37 weeks of gestation and those without
diseases that affected food intake. A strength of the study is that infants were selected at
random from an infant registry database. Weaknesses of the study were that infants from only
two areas in Denmark were studied and that only 11 out of 265 infants were of a mixed or nonCaucasian race, which may not have been representative of the countrys entire population.
Results of the study found that number of breastfeedings per day was negatively associated
with insulin concentration, meaning the more breastfeedings per day, the lower concentration of
insulin (Madsen, et. al, 2010). The practice of breastfeeding was shown to have a strong
negative effect on insulin concentration as well, with a median insulin concentration 36% lower
than those not breastfed (Madsen et. al, 2010). High insulin concentration is a risk factor for
insulin resistance later in life, which can ultimately lead to type 2 diabetes. Therefore reduction
in insulin concentration earlier in life may help reduce the risk of type 2 diabetes later in life.
In the 2016 article entitled Breastfeeding in the 21st century: epidemiology,
mechanisms, and lifelong effect, researchers studied relevant literature to determine the
presence or absence of lifelong health benefits associated with exclusive breastfeeding during
infancy. This type of evidence is considered level 1. Part of the authors research involved
studying the health benefits of breastmilk. Using the current data, researchers found that
breastfed infants have lower instances of metabolic syndrome and diabetes as adults. After
continuing to study established literature and accumulate data from various resources, the
researchers used their information to create estimates of potential lives saved worldwide due to
breastfeeding. Based on the data, they estimated that in 2015, if breastfeeding rates in low and

middle-income countries had been raised to the global rate, 823,000 infant deaths would have
been prevented. The authors agreed that some of these deaths were related to metabolic
syndrome and diabetes. Therefore, the researchers concluded that breastfeeding improves
mortality and morbidity, including rates relative to metabolic syndrome and diabetes.
In 2016, European researchers conducted an experiment to determine whether or not
exclusive breastfeeding reduces future cardiometabolic risk. The journal article, entitled Effects
of promoting longer-term and exclusive breastfeeding on cardiometabolic risk factors at age
11.5 years, describes how the researchers used a sample size of 17,046 healthy, breastfed
infants in their trial. The inclusion criteria were strict, based on the health of the neonates at
birth. The experiment was a cluster-randomized, controlled trial with interventions being applied
to certain groups, with other groups used as controls. Therefore, this article provides us with
level 2 evidence. Certain groups received continuous breastfeeding promotion and education.
These groups breastfed exclusively, while the control group either breastfed intermittently or not
at all. When the children reached age 11.5, cardiometabolic function tests were performed using
dried blood spot sampling and assays. These research methods were tested and found to be
both valid and reliable. Based on the data obtained, the researchers found that experimental
intervention (breastfeeding) did not lead to statistically significant reduction in cardiometabolic
risk or insulin resistance. The researchers findings are incongruent with the majority of the data
found in our research, and their study had several limitations, the first of which being time.
Because they only studied the participants into the pre-teen years, they cannot say whether or
not they will develop cardiometabolic risk factors in the future.
Overall, many of the studies show very similar outcomes: Breastfeeding is linked to a
decrease incidence of obesity and diabetes in children. Many of the studies examine the effect
of breast milk on insulin utilizations, while others use tools such as growth charts to track the
childrens size over time. Although most studies agree that breastfeeding reduces obesity and
diabetes risks later in childhood, one experiment found no correlation between implementation
of breastfeeding interventions on future metabolic risk (Martin et. al., 2016). However, the
researchers stated that their experiment had several weaknesses, and that there is robust
evidence worldwide to support implementation of exclusive breastfeeding after birth.
There are also differences found among the articles used for our research topic. The
articles used range in evidence from level 1 to level 7. A majority of the articles are from
systematic reviews or meta-analyses that examine studies from several databases. A few other
articles are cohort/prospective or cross-sectional studies, which aim at looking at a specific
population in time and finding risk factors among this population. A study of level 7 evidence
also helps to strengthen the results of our research by helping to narrate the opinion of a
professional in the medical field on how breastfeeding versus bottlefeeding is perceived by new
mothers (Tusa et. al, 2001). Another difference among the articles chosen for our research topic
is the age of the population studied. Some articles included a broad age range, such as the
study done by Horta et. al (2015) in which infants after age one, adolescents, and adults were
studied. Other research articles, however, only examined the effects of breastfeeding on a
specific age group. In the article Determinants of blood glucose and insulin in healthy 9-month-

old term Danish infants; the SKOT cohort only infants of nine months of age were examined
(Madsen et. al, 2010). One final difference worth noting is that a couple of the research articles
found also examined the benefits of breastfeeding to the mothers health. In the article
Beneficial effects of breastfeeding in Women with Gestational Diabetes Mellitus, breastfeeding
for at least 3 months was shown to possibly decrease the risk of type 2 diabetes in mothers with
gestational diabetes (Much et. al, 2014). In a study by Kalra et. al (2015), breastfeeding was
shown to decrease the risk of obesity and diabetes in both the baby and the mother. Although
our research topic focused on the decreased risk of disease in infants who were breastfed
versus being bottlefed, it is still important to take into consideration the mothers health in the
process.
One recommendation for nurses based on these studies is to discuss all feeding options
with the mother in a factual, unbiased manner and provide as much verbal and physical
information as possible. Other recommendations include: instructing the mother on pumping
and bottled milk storage, observe feeding routine and use positive reinforcement and problem
identification to increase effectiveness of any method of feeding, and to refer mother to support
groups and newborn nutrition consultants to educate and increase mothers confidence of
feeding.
3. Linking Evidence to Practice

Discuss all feeding options with the mother in a factual, unbiased manner and provide as much
verbal and physical information as possible
Instruct the mother on pumping and bottled milk storage
Observe feeding routine and use positive reinforcement and problem identification to increase
effectiveness of any method of feeding
Refer mother to support groups and newborn nutrition consultants to educate and increase
mothers confidence of feeding
4. References

Horta, B. L., Mola, C. L., & Victora, C. G. (2015). Long-term consequences of breastfeeding on
cholesterol, obesity, systolic blood pressure and type 2 diabetes: A systematic review and
meta-analysis. Acta Paediatrica, 104, 30-37. doi: 10.1111/apa.13133
Kalra B., Gupta Y., and Karla S. (2015). Breast feeding: preventive therapy for type 2
diabetes.Journal Of Pakistan Medical Association, 65(10). 1-25. Retrieved from
http://jpma.org.pk/full_article_text.php?article_id=7505
Madsen, A. L., Schack-Nielsen, L., Larnkjaer, A., Mlgaard, C., & Michaelsen, K. F. (2010).
Determinants of blood glucose and insulin in healthy 9-month-old term Danish infants;
the SKOT cohort. Diabetic Medicine, 27(12), 1350-1357. doi: 10.1111/j.14645491.2010.03134.x

Mamun, A., OCallaghan, M., Williams, G., Najman, J., Callaway, L., & McIntyre, H. (2015).
Breastfeeding is protective to diabetes risk in young adults: a longitudinal study.
Acta Diabetologica, 52(5), 837-844. DOI: 10.1007/s00592-014-0690-z
Martin, R., Patel, R., Kramer, M., Vilchuck, K., Bogdanovich, N., & Sergeichick, N.(2013).
Effects of Promoting Longer-Term and Exclusive Breastfeeding on Cardiometabolic Risk
Factors at Age 11.5 Years: A Cluster-Randomized, Controlled Trial. Circulation, 129(3),
321-329. DOI: 10.1161/circulationaha.113.005160
Mayer-Davis, E. J., Rifas-Shiman, S. L., Zhou, L., Hu, F. B., Colditz, G. A., & Gillman, M. W.
(2006, October). Breast-Feeding and Risk for Childhood Obesity: Does maternal diabetes
or obesity status matter? Retrieved March 15, 2016, from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3210833/
Much, D., Beyerlein, A., Robauer, M., Hummel, S., & Ziegler, A. (2014). Review: Beneficial
effects of breastfeeding in women with gestational diabetes mellitus. Molecular
Metabolism, 3(Metabolic Syndrome: Removing Road Blocks to Therapy), 284-292.
doi:10.1016/j.molmet.2014.01.002
Pereira, P. F., Alfenas, R. C., & Araujo, R. M. (2014). Does breastfeeding influence the risk of
developing diabetes mellitus in children? A review of current evidence. Jornal de
Pediatria, 90(1), 7-15. DOI: 10.1016/j.jpedp.2013.02.010
Rothfus, M. (2012). The Breast vs. Bottle Battle: Infant Feeding Mis/Information. DJIM
Dalhousie Journal of Interdisciplinary Management, 8(1). Retrieved March 15, 2016,
from https://ojs.library.dal.ca/djim/article/view/2012vol8Rothfus.
Tusa, S., Bidwell, R., & Boyd, B. (2001). BabyTalk breast vs. bottle poll. Baby Talk, 66(7), 38.
Victora, C., Bahl, R., Barros, A., Frana, G., Horton, S., & Krasevec, J.. (2016). Breastfeeding in
the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet, 387.
Retreived March, 2016 from http://www.ncbi.nlm.nih.gov/pubmed/26869575
Wahlqvist, M. L., Krawetz, S. A., Rizzo, N. S., Dominguez-Bello, M. G., Szymanski, L. M.,
Barkin, S., . . . Kral, J. G. (2015), Early-life influences on obesity: from preconception to
adolescence. Annals of the New York Academy of Sciences, 1347, 128. doi:
10.1111/nyas.12778