Breastfeeding in the Prevention of Chronic Diseases

Juliet Sio Aguilar, M.D., M.Sc.(Birm) Professor of Pediatrics University of the Philippines Manila Wellstart Associate
Presented at the XXIII International Congress of the Fetus as a Patient International Society 16 March 2007, EDSA Shangri-LA Manila

WHO and UNICEF: Global Strategy for Infant and Young Child Feeding (2002)

To revitalize focus on impact of feeding practices on nutritional status, growth and development and health, and ultimately the survival of infants and young children .health and other relevant sectors protect, promote and support exclusive breastfeeding for six months and continued breastfeeding up to two years or beyond

Impact of Breastfeeding
Fetal Origins of Adult Diseases Obesity Diabetes Allergic Disorders

Does breastfeeding protect against obesity in children and on to adulthood?

Early Nutrition and Later Obesity

Fig. Hypotheses about early childhood nutrition and later adiposity.

Martorell R, Stein AD, Schroeder DG. J Nutr 2001; 131:874S.

Undernutrition and Later Obesity: Possible Mechanisms

Development of disproportionately high fat mass in a setting of low muscle mass Overgrowth of limited cell mass during period of catch-up growth Persistence of secretion of hormones (insulin, insulin-like growth factor 1, growth hormone) established in utero
Eriksson JG, Forsn T, Tuomilehto J, Winter PD, Osmond C, Barker DJP. BMJ 1999; 318: 427.

Growth Patterns in Breastfed and Formula-fed Infants

DARLING Study
Breastfed

infants

Leaner with mean weight-for-length at 12 mos = 0.2-0.6 SD below NCHS median infants Larger skinfold thicknesses in later infancy (9-15 mos)
Dewey KG et al. AJCN 1992; 56: 1012.

Formula-fed

Breastfeeding and Childhood Obesity: A Meta-analysis

Nine studies with >69,000 participants with prospective study protocol

Early

feeding mode

Result
Breastfeeding

reduced risk of obesity in childhood significantly AOR = 0.78 [95% CI: 0.71, 0.85]
Arenz S, Rckerl R, Koletzko B, von Kries R. Int J Obes 2004; 28: 1247.

Duration of Breastfeeding and Risk of Overweight: A Meta-analysis

17 studies with 120,828 subjects Meta-regression analysis

Duration of BF inversely associated with risk of overweight [r=0.94, 95% CI: 0.89, 0.98]

Harder T, Bergmann R, Kallischnigg G, Plagemann A. Am J Epidemiol 2005; 162: 397.

Duration of Breastfeeding and Risk of Overweight: A Meta-analysis

Duration of Breastfeeding
<1 mos Odds ratio for overweight 95% CI No. of durationspecific study estimates 1-3 mos 4-6 mos 7-9 mos >9 mos

1.0
0.65, 1.55 5

0.81
0.74, 0.88 14

0.76
0.67, 0.86 15

0.67
0.55, 0.82 11

0.68
0.50, 0.91 7

Dose-response Relationship between Duration of BF and Risk of Overweight

Harder T, Bergmann R, Kallischnigg G, Plagemann A. Am J Epidemiol 2005; 162: 397.

Effect of Breastfeeding on the Risk of Obesity Across the Life Course

[28 studies; 298,900 subjects]
Parsons et al (33) Poulton & Williams (26) Tulldahl et al (16) Kramer (15) Kramer (15) Elliot et al (15) Gillman et al (12) Sung et al (11) Toschke et al (6-14) Liese et al (10) Frye and Heinrich (10) Maffeis et al (10) Li et al (8) Eid (8) Strbak et al (1-7) Richter (7) Wadsworth et al (6) Von Kries et al (6) Bergman et al (6) Scaglioni et al (5) OCallaghan et al (5) Neyzi et al (5) Hediger et al (4) Grummer-Strawn & Mei (4) Armstrong & Reilly (3) Thorogood et al (1) Dewey et al (1) Yeung et al (0.5) Taitz (0)

Owen C et al. Pediatrics 2005; 115: 1367.

Mean ages (in yrs) at which obesity status was measured

Combined OR = 0.87 [95%CI: 0.85, 0.89]

Breastfeeding better 0.5 ODDS of OBESITY
1.5 1 Formula feeding better

Exclusivity of Breastfeeding and Risk of Obesity Across the Life Course: Subgroup Analysis

Protective effect of BF over obesity stronger and more homogeneous if exclusively BF

n = 37,170 OR = 0.76 [95% CI: 0.70, 0.83]

Hediger ML et al. JAMA 2001; 285: 2453. Armstrong J, Reilly JJ. Lancet 2002; 359: 2003. Liese AD et al. Int J Obes Relat Metab Disord. 2001; 25: 1644. Neyzi G et al. Human Growth and Development. New York: Plenum; 1984: 603.

Why BF Protects vs. Obesity: Plausible Mechanisms

Learned self-regulation of energy intake

Metabolic programming in early life

higher protein intake stimulate higher insulin secretion higher plasma insulin in formula-fed infants stimulate fat deposition and early development of adipocytes

Properties in breast milk

bioactive factors which modulate EGF and TNF inhibit adipocyte differentiation
Dewey KG. J Hum Lact 2003; 19:9. Von Kries R et al. BMJ 1999; 319:147.

Does breastfeeding alter the risk of

Breastfeeding and Type 2 Diabetes in Later Life: Quantitative Analysis

23 studies Results among BF vs formula-fed

Lower risk of type 2 DM in later life 7 studies with 76,744 subjects OR = 0.61 [95% CI: 0.44, 0.85] p=0.003 Lower mean preprandial blood glucose 12 studies with 560 subjects Mean diff = -0.17 mmol/L [95%CI: -0.28, -0.05] p=0.005 Lower mean insulin concentration 7 studies with 291 subjects Mean diff = -2.86 pmol/L [95%CI: -5.76, 0.04] p=0.054
Owen CG et al. Am J Clin Nutr 2006; 84: 1043.

Breastfeeding and Genetic Risk of IDDM

2,949 Finnish infants with increased genetic risk of IDDM (HLA typing)

monitored 3-6-mo intervals for four islet cell antibodies 65 infants seropositive before 4 yr-old compared to 390 controls seronegative Exclusive BF >4mos lowers risk of seroconversion OR = 0.17 [95% CI: 0.03, 0.86] Introduction of cow milk <4mos increases risk of seroconversion <2m: OR = 5.02 [95% CI: 1.27, 19.89] 2-3.9m: OR = 6.19 [95% CI: 1.10, 34.84]

Kimpimaki T et al. Short-term exclusive breastfeeding predisposes young children with increased genetic risk of Type I diabetes to progressive beta-cell autoimmunity. Diabetologia 2001; 44: 63.

Why Breastfeeding Decreases Diabetes Risk

Diabetes risk related more to early exposure to cow milk

Bovine albumin serves as trigger Ab to bovine albumin react with pancreatic -cell surface protein
Karjalainen J et al. NEJM 1992; 327: 302.

Bovine -casein targets humoral and cellular immune responses of IDDM pts

Ab to bovine -casein elevated in IDDM and babies fed with cow milk but not in babies exclusively breastfed for 4 mos
Monetini L et al. Diabetes Metab Res Rev 2001; 17: 51.

Does breastfeeding reduce the risk for developing allergic diseases?

Allergic Diseases

Increased prevalence in last decades Its development depends on complex interaction between genetic and environmental factors
Environmental

factors: food and inhalant allergens; non-specific adjuvant factors (e.g., tobacco smoke, air pollution, infections) Genetics: account for ~50% of allergic diseases

Exclusive Breastfeeding (>3m) and Allergic Diseases: Meta-analyses

Atopic Dermatitis
Summary Odds Ratio 95% CI Odds ratio for FH atopy 95% CI No. of prospective studies (period of review) 0.68 0.52, 0.88 0.58

Allergic Rhinitis
0.74 0.54, 1.01 0.87

Asthma
0.70 0.60, 0.81 0.52

0.42, 9.92

0.48, 1.58

18 6 12 (1966-2000) (1966-2000) (1966-1999)

Gdalevich M et al. J Am Acad Dermatol 2001; 45: 520. Mimouni BA et al. Acta Pediatr 2002; 9: 275. Gdalevich M et al. J Pediatr 2001; 139: 261.

Other Observations in Allergic Disease Reduction

Partial BF (>6m)
reduced risk of asthma AOR = 0.69 [95% CI: 0.52, 0.91] up to age 2 yrs reduced risk of multiple allergic disease AOR = 0.69 [95% CI: 0.50, 0.95] up to age 2 yrs

Exclusive BF (>4m)
reduced risk of multiple allergic disease AOR = 0.66 [95% CI: 0.48, 0.90] up to age 2 yrs
Kull I, Wickman M et al. Arch Dis Child 2002; 87: 478.

Breastfeeding, Maternal IgE and Total serum IgE in Childhood

Prospective study of 664 children with 1,457 observations

Tucson Childrens Respiratory Study enrolled at birth serum IgE assessed

Results

Kids with mothers in lower tertiles of IgE

BF assoc with lower total serum IgE at 6 yrs old vs never BF (24.2 vs 44.3 IU/ml) BF > 4m with higher IgE vs no BF or BF < 4m vs 38.9 IU/ml) (97.0

Kids with mothers in highest tertile of IgE

Wright AL et al. J Allergy Clin Immunol 1999; 104: 589.

How BF Reduces Allergic Diseases and the Implications

Protective effect due to:

immunological components of breast milk (i.e., sIgA) alter susceptibility to infection growth factors in breast milk facilitate maturation of organs (including lung)

Wright AL et al. Thorax 2001; 56: 192.

Early onset of atopic dermatitis

predictive of asthma later in childhood Increases risk of having disease over many decades
Kull I, Wickman M et al. Arch Dis Child 2002; 87: 478.

Asthma with other allergic diseases in early life

Impact of Breastfeeding in Disease Prevention

Exclusive breastfeeding for at least 6 mos

Exclusive breastfeeding for at least 4 mos Breastfeed for at least 6 mos Caution in severe maternal asthma Exclusive breastfeeding for at least 4 mos Delay introduction of cows milk until 4 mos

Lets all help bring back the breastfeeding culture.