8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
1/25
Breastfeeding in the
Prevention of ChronicDiseasesJuliet Sio Aguilar, M.D., M.Sc.(Birm)
Professor of PediatricsUniversity of the Philippines Manila
Wellstart Associate
Presented at the XXIII International Congress of the Fetus as a Patient International Society16 March 2007, EDSA Shangri-LA Manila
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
2/25
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
3/25
Impact of Breastfeeding
Fetal Origins of Adult Diseases
Obesity
Diabetes
Allergic Disorders
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
4/25
Does breastfeeding protect
against obesity in children
and on to adulthood?
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
5/25
Martorell R, Stein AD, Schroeder DG. J Nutr2001; 131:874S.
Fig. Hypotheses about early childhood nutrition and later adiposity.
Early Nutrition and
Later Obesity
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
6/25
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 ofcatch-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.
BMJ1999; 318: 427.
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
7/25
Growth Patterns in Breastfed and
Formula-fed Infants
DARLING Study
Breastfed infants
Leaner with mean weight-for-length at 12mos = 0.2-0.6 SD below NCHS median
Formula-fed infants
Larger skinfold thicknesses in later infancy(9-15 mos)
Dewey KG et al.AJCN 1992; 56: 1012.
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
8/25
Breastfeeding and Childhood
Obesity: A Meta-analysis
Nine studies with >69,000 participants withprospective 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 Obes2004; 28: 1247.
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
9/25
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 Epidemiol2005; 162: 397.
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
10/25
Duration of Breastfeeding and Risk of
Overweight: A Meta-analysis
Duration of Breastfeeding9 mos
Odds ratio for
overweight1.0 0.81 0.76 0.67 0.68
95% CI0.65,
1.55
0.74,
0.88
0.67,
0.86
0.55,
0.82
0.50,
0.91
No. of duration-specific study
estimates
5 14 15 11 7
Harder T, Bergmann R, Kallischnigg G, Plagemann A.Am J Epidemiol2005; 162: 397.
Dose-response Relationship between Duration of BF and Risk of Overweight
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
11/25
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)
Breastfeeding better ODDS of OBESITY
Owen C et al.
Pediat r ics 2005; 115: 1367.
Combined OR = 0.87[95%CI: 0.85, 0.89]Mean ages (in yrs) at which
obesity status was measured 0.5 1 1.5
Formula feeding better
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
12/25
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. JAMA2001; 285: 2453.
Armstrong J, Reilly JJ. Lancet2002; 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.
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
13/25
Why BF Protects vs. Obesity:
Plausible Mechanisms Learned self-regulation of energy intake
Metabolic programmingin early life higher protein intake stimulate higher insulin secretion higher plasma insulin in formula-fed infants
stimulate fat deposition and early development ofadipocytes
Properties in breast milk bioactive factorswhich modulate EGF and TNF
inhibit adipocyte differentiation
Dewey KG. J Hum Lact2003; 19:9.
Von Kries R et al. BMJ1999; 319:147.
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
14/25
Does breastfeeding alter
the risk of
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
15/25
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 Nutr2006; 84: 1043.
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
16/25
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 >4moslowers risk of seroconversion
OR = 0.17 [95% CI: 0.03, 0.86]
Introduction of cow milk
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
17/25
Why Breastfeeding
Decreases Diabetes Risk Diabetes risk related more to early exposure to cow
milk
Bovine albuminserves as trigger Ab to bovinealbumin react with pancreatic -cell surface protein
Karjalainen J et al. NEJM1992; 327: 302.
Bovine -caseintargets humoral and cellularimmune 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 mosMonetini L et al. Diabetes Metab Res Rev2001; 17: 51.
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
18/25
Does breastfeeding reduce
the risk for developing allergicdiseases?
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
19/25
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
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
20/25
Exclusive Breastfeeding (>3m) and Allergic
Diseases: Meta-analyses
Atopic
Dermatitis
Allergic
RhinitisAsthma
Summary Odds Ratio 0.68 0.74 0.70
95% CI 0.52, 0.88 0.54, 1.01 0.60, 0.81
Odds ratio for FH atopy 0.58 0.87 0.52
95% CI 0.42, 9.92 0.48, 1.58
No. of prospective studies(period of review) 18(1966-2000) 6(1966-2000) 12(1966-1999)
Gdalevich M et al. J Am Acad Dermatol2001; 45: 520.
Mimouni BA et al.Acta Pediatr2002; 9: 275.
Gdalevich M et al. J Pediatr2001; 139: 261.
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
21/25
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.
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
22/25
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
BFassoc with lower total serum IgE at 6 yrs old vs
never BF (24.2 vs 44.3 IU/ml)
Kids with mothers in highest tertile of IgE
BF > 4mwith higher IgE vs no BF or BF < 4m (97.0
vs 38.9 IU/ml)
Wright AL et al. J Allergy Clin Immunol1999; 104: 589.
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
23/25
How BF Reduces Allergic Diseases and
the Implications
Early onset of atopic dermatitis
predictive of asthma later in childhood
Asthma with other allergic diseases in early life Increases risk of having disease over many decades
Wright AL et al. Thorax2001; 56: 192.
Protective effectdue to:
immunological components of breast milk (i.e., sIgA) alter
susceptibility to infection
growth factors in breast milk facilitate maturation of organs(including lung)
Kull I, Wickman M et al.Arch Dis Child 2002; 87: 478.
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
24/25
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
8/12/2019 Breastfeeding in the Prevention of Chronic Diseases
25/25
Lets all help bring back the
breastfeeding culture.