Breastfeeding Duration and Childhood Overweight Among Low-Income

Children in Kansas, 19982002

Sandra B. Procter, PhD, RD and Carol Ann Holcomb, PhD, CHES
Author information Article notes Copyright and License information

Abstract
Childhood overweight may be the most significant health issue facing American children today. The number of children who
are overweight in the United States has risen dramatically since the 1970s, and the prevalence of excess weight in US
children continues to increase.1 Excess weight has negative effects on children from early childhood throughout life;
therefore, research regarding causes as well as prevention and treatment of childhood overweight is needed.
Childhood overweight reflects the convergence of many biological, economic, and social factors. Each of these factors
affects family food choices, food preparation, and food consumption, and together they contribute to the complex problem of
overweight in children. No single intervention is likely to produce large reductions in the prevalence of overweight
children,2 but choosing to breastfeed an infant rather than use formula is one factor that may prevent subsequent
overweight.3 Recent studies have reported that longer breastfeeding is protective against childhood overweight.49
In 2004, Howell Wechsler, acting director of the Centers for Disease Control and Prevention Division of Adolescent and
School Health, testified before a congressional subcommittee that the promotion of breastfeeding and efforts to increase its
duration is one behavioral strategy for reducing rates of overweight and obesity in children and adolescents.10 Data from
2002 revealed that breastfeeding rates among recipients of benefits from the Special Supplemental Nutrition Program for
Women, Infants, and Children (WIC) lagged behind those of non-WIC recipients by more than 20% in the hospital and at 6
months of age.11Kansas data showed similar disparity between in-hospital breastfeeding rates (initiation) and breastfeeding
rates at 6 months (duration) for WIC infants, with only 19.6% still breastfeeding at 6 months, below even the national rate
for WIC infants of 22.1%.12 Breastfeeding is initiated in this population, but it is not continued.
Grummer-Strawn and Mei reported that prolonged breastfeeding was associated with a reduced risk of overweight in nonHispanic White children.4 Their study analyzed linked data from the Pediatric Nutrition Surveillance System (PedNSS) and
the Pregnancy Nutrition Surveillance System (PNSS) for 7 states. The PedNSS and PNSS receive data from publicly funded
health and nutrition programs, including WIC.
Little was known about breastfeeding and childhood overweight among Kansans, particularly low-income Kansans. Kansas
was not included in the 2004 study by Grummer-Strawn and Mei.4 Therefore, we designed our study to address the paucity
of data for Kansas by analyzing linked data from the PedNSS and PNSS to determine whether longer breastfeeding was
associated with decreased incidence of childhood overweight at the age of 4 years among a Kansas WIC population.
Go to:
METHODS
Data Sets

Data from the Kansas PedNSS master file for years 1998 through 2002 and the Kansas PNSS master file for children born in
1998 were obtained from the Centers for Disease Control and Prevention.
The PedNSS is a public health surveillance system that describes the nutritional status of low-income US children attending
federally funded maternal and child health and nutrition programs.13 The PedNSS contains information on birthweight,
breastfeeding (including duration), and race/ethnicity, as well as height and weight data recorded during each visit to public
health programs. The data captured information for all children born in 1998 and each of their subsequent visits to the WIC
program through 2002. Body mass index (BMI; calculated as weight in kilograms divided by height in meters squared)forage was calculated from data obtained on the visit closest to the childs fourth birthday. Because the PedNSS has multiple
records on children in each calendar year, 1 record for each child for each year was selected to avoid double counting.14
The PNSS is a public health surveillance system that monitors risk factors associated with infant mortality and poor birth
outcomes among low-income pregnant women who participate in federally funded public health programs.13 The PNSS

contains data collected during the mothers visits, including her date of birth, age at delivery, education level, prepregnancy
weight (self-reported), height, prepregnancy BMI, weight gain during pregnancy, alcohol use before and during pregnancy,
number of previous pregnancies, infants birthweight, and age when solid foods were added to the infants diet. The 1998
data captured selected variables for each Kansas WIC participant who delivered an infant that year.
Unlike in many other states in the national WIC data system, in Kansas it is possible to link a child to its mother by matching
a unique 5-digit family identification number for the child in the PedNSS that is also embedded in a 7-digit number assigned
to the mother in the PNSS. We identified the 1998 birth cohort from the PedNSS, tracked its members through 2002, and
linked them to mothers from the 1998 PNSS file.
Statistical Methods and Analysis

To determine which factors were associated with overweight at 4 years of age, characteristics of both mother and child
determined from previous research were drawn from the data sets for analysis. For initial comparison with Grummer-Strawn
and Meis results,4 we kept the same categories for birthweight and breast-feeding duration. Birthweights were categorized
as less than 2500, 2500 to 3999, or 4000 g or more. Breastfeeding duration was categorized as less than 4, 4 to 11, 12 to 23,
24 to 51, or 52 weeks or more. For BMI-for-age we were interested in 1 additional category not reported by GrummerStrawn and Mei: at risk for overweight. This category included children with a BMI-for-age between the 85th and 94th
percentiles. Therefore, we divided BMI-for-age into 4 categories: lower than 5th percentile (underweight), 5th to 84th
percentile (normal weight), 85th to 94th percentile (at risk for overweight), and 95th percentile or higher (overweight). We
based our definitions of these weight categories for 4-year-old children on the 2000 Centers for Disease Control and
Prevention gender-specific growth charts.15
We used the linked data from the PNSS to identify and categorize several maternal characteristics.We used the 2 procedure
to analyze differences in characteristics between the 22804 children in the PedNSS data who were born in 1998 and the 3692
children in the linked data set. This analysis contained the following variables: gender, race/ethnicity, birthweight, BMI-forage, and breastfeeding duration.
We used the 2 analysis to assess differences in the proportion of children in each of the 4 weight categories according to
duration of breastfeeding. Mean BMI derived from the raw values for BMI at 4 years of age were compared across all 6
lengths of breastfeeding with a 1-way analyses of variance (repeated-measures analysis of variance) procedure.
Five variables identified in the research literature as risk factors for overweight at 4 years of age were the childs gender,
race/ ethnicity, and birthweight; the mothers prepregnancy BMI; and formula use versus breastfeeding duration. We
included these 5 factors in a univariate analysis of independent association with overweight at 4 years of age in our linked
data set. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) using binary logistic regression to determine
which factors could be considered as confounding variables.
In the final analysis, breastfeeding duration was categorized into tertiles to provide a relatively even distribution of children
at each level. Crude and adjusted ORs and 95% CIs were calculated for 3 samples stratified by ethnicity. Initially, all sample
participants were included in both models; Hispanics were then eliminated in both models, and finally, only Whites were
included in both models. The P for trend in each of the 6 subgroups was determined with the Wald statistic. All analyses
were performed with SPSS for Windows version 13 (SPSS Inc, Chicago, Ill).
Go to:
RESULTS
Population Characteristics

Table 1 compares the total sample in the PedNSS data set with the subset of participants linked to mothers data from the
PNSS. There was no significant difference in the proportion of male and female infants in the 2 groups. There was a
significantly higher proportion of Hispanics in the linked data set (28.1%) than in the original PedNSS data set (21.6%).
Although these levels were 3 to 4 times higher than were those found in the Kansas general population (7.0%) in
2000,16 they were reflective of the relatively high number of Hispanics participating in the Kansas WIC program, which
reached 30.6% in 2006 (e-mail communication from Patricia Dunavan, nutrition education specialist, Kansas WIC, March
27, 2006).

TABLE 1
Sample Characteristics of Children and Mothers, by Data Set: Pediatric Nutrition Surveillance System (PedNSS) and
the Pregnancy Nutrition Surveillance System (PNSS), Kansas, 19982002
No significant difference was found in the proportion of infants born in each of the 3 birthweight categories in the 2 sample
sets. However, BMI-for-age differed significantly between the PedNSS data and the linked data, with children from the
linked data set less likely to be underweight (3.5% vs 5.5%) or normal weight (65.5% vs 73.7%) and more likely to be at risk
for overweight (15% vs 12.6%) or overweight (16% vs 8.2%).
We found that significantly fewer children were never breastfed in the linked data subset (36.3%) than in the original
PedNSS data set (49.5%). In addition, significantly more children were breastfed for 52 weeks or more in the linked data
group (11.9%) than in the PedNSS data set (2.4%).
Data Characteristics

Table 2 summarizes the sample distribution by duration of breastfeeding in the linked data sets as well as the distribution
across weight categories, from overweight to underweight. Table 2 also shows the mean BMI-for-age by breastfeeding
duration. No significant difference was found in the proportion of participants in each weight category by breastfeeding
duration. We found no significant difference in the mean BMI-for-age of the 4-year-old children by breastfeeding duration.
Increased breastfeeding decreased mean BMI variance, with the BMI variance nearest the mean for those children breastfed
the longest. An emergent patternthe trend of an inverse association between increased breastfeeding duration and
decreased proportion of overweight at 4 years of ageis shown but is not consistent across the sample as a whole.

TABLE 2
Linked Data Showing Number and Percentage of Children in Each Weight Category and Mean BMI at Age 4 Years,
by Breastfeeding Duration: Pediatric Nutrition Surveillance System and Pregnancy Nutrition Surveillance System,
Kansas, 19982002
Table 3 shows the results of univariate analyses of potential confounding factors or variables other than the main exposure
or independent variable of breastfeeding duration that might be associated with overweight at 4 years of age. Three separate
analyses with logistic regression were performed. ORs are shown with tests of significance reflected within the 95% CIs for
each OR. For each variable, the first category listed was set as the null or reference category. In the total linked sample, all 5
factors (gender, ethnicity, birthweight, mothers BMI, and formula use) were significantly associated with overweight at 4
years of age. In the second analysis, data for Hispanics were eliminated, and the remaining 4 variables were significant. In
the third analysis for Whites only, 3 factors (birthweight, mothers BMI, and formula use) were found to be significantly
associated with overweight at 4 years of age. These variables were considered confounding variables in the subsequent
multivariate models.

TABLE 3
Univariate Analysis of Linked Data Showing Associations Between Potential Confounding Variables and Overweight
in Children Aged 4 Years: Pediatric Nutrition Surveillance System and Pregnancy Nutrition Surveillance System,
Kansas, 19982002
Table 4 presents multivariate analyses of independent variables in the model with the outcome variable of overweight the
dependent variable. We performed 3 separate multivariate logistic regression procedures by race/ethnic group. The
unadjusted model contained only 2 variables: the main exposure variable of breastfeeding duration at 3 exposure levels and
the outcome variable of overweight at 4 years of age. The fully adjusted models contained the significant variables from the
univariate analyses (Table 3).

TABLE 4
Linked Data Showing Association Between Breastfeeding Duration and Overweight Among Children Aged 4 Years:
Pediatric Nutrition Surveillance System and the Pregnancy Surveillance System, Kansas, 19982002
Considered independently, breastfeeding duration showed a significant protective association with overweight at 4 years of
age for all non-Hispanics (OR = 0.72; 95% CI = 0.55, 0.94) and for Whites only (OR = 0.68; 95% CI = 0.50, 0.92). When
we controlled for other significant risk factors for overweight at 4 years of age, the association diminished and was not
statistically significant.
Go to:
DISCUSSION
Before we adjusted our model, breastfeeding for 9 weeks or more was found to be mildly protective against overweight at 4
years of age among non-Hispanics. Other risk factors for child overweight at 4 years of age, howeverincluding being
Hispanic, being male, having a high birthweight, having a mother with a high prepregnancy BMI, and being fed infant
formula along with breastfeedingappeared to lessen or offset the protective influence of breastfeeding for 9 weeks or
more.
Although numerous studies support the protective association of increased breastfeeding duration against childhood and
adolescent overweight, other studies do not. Burke et al. did not find the duration of breastfeeding to be associated with a
childs risk of being overweight between 1 and 8 years of age.17Hediger et al. found a reduced risk of being at risk of
overweight for ever-breastfed children but no reduced risk of being overweight.18 When the 2 weight categories were
combined in another study, the investigators found a significant association.9 A 2006 study that used dual-energy X-ray
absorptiometry to examine 5-year-old childrens body composition found neither breastfeeding nor the timing of the
introduction of complementary foods to be associated with adiposity.19
We examined the relationship between breastfeeding duration and overweight in a Kansas WIC population. Other recent
studies have explored a relationship between WIC and overweight in children, with particular focus on the programs
practice of providing infant formula as a mediating factor.20 The relationship of the WIC program itself, and the effect of
providing formula, to later overweight status offer intriguing future research opportunities.
Our study had several limitations. Grummer-Strawn and Mei raised a question with their study that is true of ours as
well.4 They noted that women who breastfeed for longer durations could be different from women who do not breastfeed in
ways not measured by the variables that we considered.4(pe85) Although our sample included all usable linked data from each
motherchild pair with at least 1 WIC visit annually during the study period, selection bias could have occurred when
potential study participants did not continue their WIC participation. Also, breastfeeding data available from the PedNSS,
although valuable, were not detailed enough to differentiate exclusive from partial breastfeeding.
No single factor has been shown to protect a child from overweight, and accordingly, no single trait or practice can be
identified as the cause of childhood overweight. Our study design provided consistency with other studies,4,9 which allows
comparison and possible replication. Earlier researchers identified possible biological bases for breastfeedings protective
effect against overweight.21
In theory, breastfeeding duration is likely 1 factor in a series of ecological influences that affect a childs propensity for
overweight. Our results indicated that children of mothers with prepregnancy BMIs in the overweight or obese categories
were more likely to be overweight at age 4 years. Li et al. determined that the combined interaction between maternal
prepregnancy obesity and lack of breastfeeding resulted in the greatest risk of children becoming overweight.22 Hediger et
al. found that the proportion of overweight children nearly tripled with maternal overweight status and more than quadrupled
with maternal obesity status.18 Our results and those of others4 showing protective effects of longer breastfeeding against
overweight in non-Hispanic participants suggest that cultural and environmental factors may override those protective
benefits. Additional research should examine not only breastfeedings effect but also the effects of ethnicity and culture,
maternal prepregnancy BMI, and childs birthweight and gender as factors influencing overweight in children.
Although it is not possible to claim a simple causal relationship between extended breastfeeding and lower risk of childhood
overweight, our study adds support for an associated protective link between the two. Our results corroborate previous
research that identified the protective effect of breast-feeding duration against child overweight in non-Hispanic children at 4

years of age and support the current public health emphasis in this country on increasing breastfeeding initiation and
duration.
Go to:
Acknowledgments
The authors acknowledge the valuable contributions of Patricia Dunavan and Mary Washburn, for information about the
Kansas Special Supplemental Nutrition Program for Women, Infants, and Children and assistance with accessing data, and
Carol MacGowan and Ellen W. Borland, for access to participant data from the Pediatric Nutrition Surveillance and
Pregnancy Nutrition Surveillance Systems via the Centers for Disease Control and Prevention. Paula Peters, Kansas State
Research and Extension and Department of Human Nutrition; Valentina Remig, Department of Human Nutrition; and Ann
Murray, School of Family Studies and Human Sciences, Kansas State University, Manhattan, reviewed the article and
contributed valuable suggestions.
Human Participant Protection
The institutional review board of the Kansas Department of Health and Environment Bureau of Children, Youth, and
Families and the committee on research involving human subjects at Kansas State University reviewed and approved the
study protocol.
Go to:
Notes
Peer Reviewed
Contributors
S.B. Procter reviewed the literature, designed the study, assisted in data extraction and analysis from the files of the Centers
for Disease Control and Prevention, and wrote the article. C.A. Holcomb assisted with project design, directed and
supervised data extraction and analysis, provided comments for the article, and reviewed the article.
Go to:
References
1. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and
adolescents, 19992000. JAMA. 2002; 288:17281732. [PubMed]
2. Strauss RS, Pollack HA. Epidemic increase in childhood overweight, 19861998. JAMA. 2001;286:2845
2848. [PubMed]
3. Dietz WH, Gortmaker SL. Preventing obesity in children and adolescents. Annu Rev Public Health. 2001;22:337
353. [PubMed]
4. Grummer-Strawn LM, Mei Z. Does breastfeeding protect against pediatric overweight? Analysis of longitudinal data from
the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System. Pediatrics. 2004;113:e81
e86. [PubMed]
5. Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of breastfeeding and risk of overweight: a metaanalysis. Am J Epidemiol. 2005;162:397403. [PubMed]
6. Arenz S, Ruckerl R, Koletzko B, von Kries R. Breast-feeding and childhood obesitya systematic review. Int J Obes
Relat Metab Disord. 2004;28:12471256. [PubMed]
7. Armstrong J, Reilly JJ, Child Health Information Team. Breastfeeding and lowering the risk of childhood obesity. Lancet.
2002;359:20032004. [PubMed]
8. von Kries R, Koletzko B, Sauerwald T, et al. Breast feeding and obesity: cross-sectional study. BMJ. 1999;319:147
150. [PMC free article] [PubMed]

9. Heinig MJ, Dewey K. Overweight and Obesity in Children and Their Mothers: Does Breastfeeding Make a
Difference? Davis, Calif: Regents of the University of California; 2004. Independent Study Module No. 020406.
10. Centers for Disease Control and Prevention, Division of Adolescent and School Health. HHS efforts to combat the
obesity epidemic among children and adolescents. Available
athttp://www.cdc.gov/washington/testimony/Ob6162004204.htm. Accessed September 3, 2004.
11. Ryan AS, Zhou W. Lower breastfeeding rates persist among the Special Supplemental Nutrition Program for Women,
Infants, and Children participants, 19782003. Pediatrics. 2006;117:11361146. [PubMed]
12. Abbott Laboratories, Ross Products Division. Breastfeeding trends2002. Mothers survey. Available
at:http://abbottnutrition.com/resources/en-US/home/breastfeeding/BF_Trends_2003.pdf. Accessed June 2004.
13. Centers for Disease Control and Prevention. Pediatric and Pregnancy Nutrition Surveillance System. What is
PedNSS/PNSS? Available at: http://www.cdc.gov/pednss/what_is. Accessed April 20, 2006.
14. Mei Z, Scanlon KS, Grummer-Strawn LM, Freedman DS, Yip R, Trowbridge FL. Increasing prevalence of overweight
among US low-income preschool children: the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance,
1983 to 1995. Pediatrics [online version]. 1998;101. Available at:http://www.pediatrics.org/cgi/content/full/101/1/e12.
Accessed April 22, 2004.
15. Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts for the United States: methods and
development. Vital Health Stat 11. 2002. May (246):1190. [PubMed]
16. Krider C, Clifford N. Demographic Changes in Kansas: Implications for State Policy. Lawrence: University of Kansas,
Kansas Center for Community Economic Development, Policy Research Institute; 2001: 2733. Technical Report Series,
No. 53, prepared for the Kansas Futures Committee, Kansas Legislature.
17. Burke V, Beilin LJ, Simmer K, et al. Breastfeeding and overweight: longitudinal analysis in an Australian birth cohort. J
Pediatr. 2005;147:5661. [PubMed]
18. Hediger ML, Overpeck MD, Kuczmarski RJ, Ruan WJ. Association between infant breastfeeding and overweight in
young children. JAMA. 2001; 285:24532460. [PubMed]
19. Burdette HL, Whitaker RC, Hall WC, Daniels SR. Breastfeeding, introduction of complementary foods, and adiposity at
5 y of age. Am J Clin Nutr. 2006;83: 550558. [PubMed]
20. Rose D, Bodor JN, Chilton M. Has the WIC incentive to formula-feed led to an increase in overweight children? J Nutr.
2006;136:10861090. [PubMed]
21. Dewey KG. Is breastfeeding protective against child obesity? J Hum Lact. 2003;19:918. [PubMed]
22. Li C, Kaur H, Choi WS, Huang TT, Lee RE, Ahluwalia JS. Additive interactions of maternal prepregnancy BMI and
breast-feeding on childhood overweight. Obes Res. 2005;13:362371. [PubMed]