Fetal and early postnatal origins of adult disease

GHRELIN, LEPTIN AND IGF-I

LEVELS IN BREAST-FED INFANTS
F. Savino, MD Breast milk

From animal studies it emerges that early life environment

affects food intake,
intake, energy intake,
intake, food preference and overall
longevity
Human studies have shown that there is a link between fetal
and early life growth and conditions and risk of obesity in later
life
Department of Paediatrics, University of Torino, Italy Cripps RL et al. Clinical Science 2005

I will talk about the physiology of breast-fed infants. There is Evidence emerged from animal studies that early life environment
growing evidence that nutrition during pregnancy and during the affects food intake, energy intake, food preference, and overall
first months after birth has long-term consequences for health and longevity. Also human studies have shown that there is a link
well being later in life. And it is important to understand how between fetal and early life growth and conditions and risk of
early diet can influence the development of risk factors of later obesity in later life.
diseases.
Human epidemiological studies have shown relationships
between low birth weight, low weight at 1 year and catch up
NUTRITIONAL PROGRAMMING growth in childhood and increased risk of adverse outcomes
through altered body composition in later life: cardiovascular
diseases,
diseases, type 2 diabetes and obesity
In 1974 Drner introduced the term Barker DJ et al. Lancet 1993; Eriksson JG et al. BMJ 1999
programming
programming into the scientific literature
He proposed that:
that: Experimental studies on preterm and term infants have been
hormones conducted to test the nutritional programming hypothesis
metabolites Lucas A. et al. Lancet 2004
neurotransmitters
during critical windows in early development
pre-program
pre-program brain development,
development, functional
disorders,
disorders, disease risk and body functions in Am J Clin Nutr 2002;75:993
2002;75:9939.
human adulthood Formula feeding or overweight in infancy may increase the
later risk of obesity

40 years of animal and human studies have shown that Human milk intake was significantly associated with lower
early nutrition is a key factor for health with major biological leptin concentrations relative to fat mass in adolescence
and social implications independent of potential confounding factors
Dorner G. et al. Acta Biol Med Ger 1973

Human epidemiological studies have shown that there is a

In 1974, Drner introduced the term "programming" into the
scientific literature. He proposed that hormones, metabolites, and
neurotransmitters during critical windows in early development
pre-program brain development, functional disorders, and disease
risk. 40 years of animal and human studies have shown that early
nutrition is a key factor for health with major biological and social
implications.
relationship between low birth weight, low weight at 1 year, and
catch up growth in childhood, and increased risk of adverse
outcomes through altered body composition in later life, such as
cardiovascular diseases and obesity. And experimental studies
have been performed on preterm and term infants in London by
Lucas and colleagues, testing this nutritional programming
hypothesis. They observed that formula feeding or overweight in
infancy may increase the later risk of obesity while human milk
intake was significantly associated with lower leptin
concentrations relative to fat mass in adolescence, independent of
potential confounding factors.

Ghrelin, Leptin and IGF-I Levels in Breast-Fed Infants Francesco Savino

1
 Why did we focus on ghrelin, leptin and IGF-I? Leptin receptors
Belong to the family of class I cytokine receptors
They act as mediators between the
gastrointestinal tract, adipose tissue Five alternatively spliced forms,
forms, with transmembrane
and brain in energy balance regulation domains (Ob
(Ob--Ra;
Ra; Ob-
Ob-Rb;
Rb; Ob-
Ob-Rc;
Rc; Ob-
Ob-Rd;
Rd; Ob-
Ob-Rf)
Rf)
Leptin may prime or set the
endocrinal system at a different Only Ob
ObRb,
Rb, the long
homeostatic energy regulation balance isoform,
isoform, has all intracellular
protein motifs necessary for
Programming of relative leptin concentrations by early diet signaling via the Jack-STAT
may be one mechanism that links early nutrition with later signal transduction pathway
obesity

Possible biological mechanisms for storing throughout life Leptin circulates in the plasma as a free form or bound to
the memory
memory
of early nutritional experience and its leptin-
leptin-binding proteins (LBP), that are likely to include a
expression in adulthood soluble form of leptin receptor
Locke R. Acta Paediatr 2002; Singhal A et al. Am J Clin Nutr 2002

So this is the reason why we focus on ghrelin, leptin and IGF-1
levels in infants. They act as mediators between the
gastrointestinal tract, adipose tissue and brain in energy balance
regulation. Particularly, leptin may prime or set the endocrinal
system at a different homeostatic energy regulation balance. So
this suggests a possible biological mechanism for storing
throughout life the "memory" of early nutritional experience and
its expression in adulthood.
There are five alternatively spliced forms of the receptor, but only
Ob-Rb, the long isoform, has all the intracellular protein motifs
necessary for signaling via the signal transduction pathway. So
leptin circulates in the plasma as a free form or bound to leptin-
binding proteins that are likely to include a soluble form of the
leptin receptor.

LEPTIN
From greek __!___,
__!___, meaning thin

Discovered by Zhang et al. in 1994,

1994, when
the gene responsible for obesity in the
ob/ob
ob/ob mouse was positionally cloned

Product of the obese gene (ob

(ob),
),
localized on chromosome 7q31.3

146 aminoacid peptide hormone (16 Kda)

Kda)

mainly produced by white adipose tissue, but also by

hypothalamus, pituitary, skeletal muscle, stomach, liver,
placenta, and mammary gland
Zhang Y et al. Nature 1994
Leptin is a hormone discovered in 1994. It is produced by the ob
gene, and is mainly expressed in white adipose tissue, but also in
the hypothalamus, pituitary, skeletal muscle, stomach, liver,
placenta and mammary gland.
Listed here are the different sites of production and the situations
that lead to increases and decreases in leptin production. In
general, leptin levels in blood correlate with total body fat stores.
During fasting or weight loss, leptin decreases while it increases in
overfeeding and weight gain.

Leptin circadian rhythm

Leptin levels INCREASE at night, peaking in the middle

of the night hours (between 12 p.m and 2 a.m.)
The diurnal rhythm in circulating leptin level is opposite
to that in cortisol level in humans
This pattern represents the response to insulin secretion
during the feeding cycle
Schoeller DA et al.
al. J Clin Invest 1997
Milk, Hormones & Human Health October, 2006
2
Leptin circadian rhythm increases at night, peaking in the middle
of the night hours. And this pattern may represent the response to
insulin secretion during the feeding cycle.
Major leptin functions
Very recently, it has been observed that leptin, acting on the brain
during a restricted neonatal critical period, promotes the formation
of neural circuits that control food intake and adiposity later in
life. So leptin represents a likely hormonal mediator of the
environmental nutrient-sensing apparatus that directs metabolic
programming.

Long-term Plasma leptin concentration correlates positively with

signal to total body fat stores
inform the
brain
about fat
storage

Actions on
peripheral At birth serum leptin concentrations were found decreased in
organs: SGA infants and increased in LGA infants compared with AGA
organs:
pancreas, ones
liver,
liver, Leptin levels on the 30th and 90th days after birth correlate
skeletal significantly with BMI
muscle In infancy a positive correlation between cord blood leptin
levels and BMI has been reported for full term infants and preterm
ones
In adults leptin is positively correlated to BMI
Shekhawat PS et al.al. Pediatr Res 1998
The major function of leptin is to provide a long-term signal to Kratzsch J et al. JCE&M 2005
inform the brain about fat storage. Further, there is an action on Akcurin S et al. J Pediatr Endocrinol Metab 2005
peripheral organs such as the pancreas, liver and skeletal muscle.
Plasma leptin concentration correlates positively with total body
fat stores at different age periods. At birth, serum leptin
concentrations were found to be decreased in small for gestational
age (SGA) infants and increased in large for gestational age (LGA)
infants compared to adequate for gestational age (AGA) infants.
Leptin levels 30 and 90 days after birth correlate significantly with
BMI. In infancy, we can observe a correlation between cord blood
leptin levels and BMI that has been reported for full term infants
and preterm infants. And in adults, leptin is positively correlated
with BMI.

Leptin and Breast milk

Leptin reduces food intake by regulating the activity of neurons in
the arcuate nucleus of the hypothalamus that inhibit food intake
and stimulate energy expenditure.
Trophic action of leptin on hypothalamic neurons that
regulate feeding
Developmental programming of hypothalamic feeding circuits
Leptin promotes the
formation of neural circuits
controlling food intake and
adiposity later in life, acting on
brain during a restricted
neonatal critical period
Physiological importance of
the neonatal leptin surge for
later control of body weight
Leptin represents a likely
hormonal mediator of the
environmental nutrient-
nutrient-
sensing apparatus that directs
metabolic programming
Bouret SG et al. Clin Genet 2006
Houseknecht et al.:
al.: leptin is present in human
milk and breast milk leptin is related to maternal
adiposity
Leptin in breast milk correlates with maternal
plasma leptin concentration, even though breast
milk leptin concentration is lower than maternal
plasma leptin levels*
levels*
Could leptin be considered a possible link between maternal
body composition and neonatal growth and development?
Smith-Kirwin
Smith-Kirwin et al. showed that leptin is produced by human
mammary epithelial cells and is associated with milk fat
globules.
globules. **
More recently it has been observed that secretory epithelial
cells may transfer leptin from the blood***
blood***
* Houseknecth et al. Biochem Biophys Res Commun 1997
** Smith-Kirwin
Smith-Kirwin et al. J Clin Endocrinol Metab 1998
*** Bonnet et al. Reprod Nutr Dev 2002
Houseknecht reported that leptin is present in human milk and is
related to maternal adiposity. Leptin in breast milk correlates with
maternal plasma leptin concentration, even though breast milk
leptin concentration is lower than maternal plasma leptin levels.
So could leptin be considered a possible link between maternal
body composition and neonatal growth and development? Smith-
Kirwin showed that leptin is produced by human mammary
epithelial cells and is associated with milk fat globules. And more
recently it has been observed that secretory epithelial cells may
transfer leptin from the blood.

Ghrelin, Leptin and IGF-I Levels in Breast-Fed Infants Francesco Savino

3
 Casabiell et al. showed that human milk
contains immunoreactive leptin,
leptin, which is
identical to intact human leptin. leptin. In Does infant milk formula contain leptin?
leptin?
experimental studies on animals they
demonstrated that leptin is transferred from
the circulation to mothers
mothers milk,
milk, to the infant There was no detectable leptin in milk formula because
rat
rats stomach via the milk and then passes whey proteins added to formula are isolated from skim,
to infant
infants blood*
blood* bovine milk and leptin associated with milk fat globules would
Ucar et al. showed a positive be removed during the skimming process*
process*
correlation between breast milk leptin Lage M et al. using RIA methods detected significant and
levels and infant plasma leptin**
leptin** variable leptin concentrations in edible commercial bovine
milk with higher concentration in infant formulas**
formulas**
More recently leptin receptors have
been identified in gastric epithelial cells OConnor D et al. convey that RIA-leptin
RIA-leptin methodology can
and in the absorptive cells of mouse and not be used to determine the presence or absence in infant
human small intestine***
intestine*** formulas of leptin due to interference with supplemented iron,
emulsifiers among other additives***
additives***
* Casabiell X et al. J Clin Endocrinol Metab 1997 *Resto M et al. Pediatrics 2001
** Ucar B et al. J Pediatr Endocrinol and Metab 2000 **Lage M et al. J Endocrinol Invest 2002
*** Barrenetxe J et al. Gut 2002 ***O
***OConnor D et al. J Endocrinol Invest 2003

Casabiell showed that human milk contains immunoreactive
leptin, which is identical to intact human leptin. In experimental
studies on animals, they demonstrated further that leptin is
transferred from the circulation to the mother's milk, to the infant
rat's stomach via the milk and then passes to the infant's blood.
Ucar showed a positive correlation between breast milk leptin and
infant plasma leptin. And more recently, leptin receptors have
been identified in gastric epithelial cells, and in the absorptive
cells of mouse and human small intestine.
Leptin concentration in breast
milk during lactation
A very controversial topic currently is what happens in infant
formula? Does infant formula contain leptin? At the moment,
there are only a few papers on this topic. Resto reported that there
was no detectable leptin in formula because whey proteins added
to formula are isolated from skim bovine milk, and since leptin is
associated with milk fat globules it would be removed during the
skimming process. Meanwhile, Lage, using RIA methods,
detected significant and variable leptin concentrations in edible
commercial bovine milk with higher concentration in infant
formulas. But O'Connor conveys that RIA methodology cannot be
used to determine the presence or absence in infant formulas of
leptin due to interference with supplemented iron, emulsifiers, and
other additives. We are conducting a study in order to clarify this
topic. At the moment, it is very controversial.

Bielicki J et al. observed higher serum and breast milk

leptin levels in term infants than in preterm ones;
ones; leptin levels
declined from colostrum to transitional milk*
milk*

A: 2
23 days postpartum
B: 4
45 days postpartum
C: 6 weeks postpartum

* Bielicki J et al. Europ J Endocrinol 2004

We have to take into account that leptin concentrations in breast Serum leptin values were significantly higher in breast-
breast-fed
milk change during lactation. It has been observed that there are than in formula-fed
formula-fed infants in the first four months of life
higher serum and breast milk leptin levels in term infants than in
preterm ones. Also leptin levels decline from the colostrum to the
transitional milk.
This is the first study that we published about leptin levels in
breast-fed compared with formula-fed infants. You can see that
serum leptin levels were significantly higher in breast-fed than in
formula-fed infants in the first four months of life. Exclusive
breast-feeding is more likely to occur during the first five months.
After this period many more confounding factors may be present.

Milk, Hormones & Human Health October, 2006

4
 Savino F et al. Breast-
Breast-fed infants have higher leptin
values than formula-fed
formula-fed infants in the first four
months of life
JPEM 2004; 17: 1527-1532

1,6 Leptin levels were found to be

1,4
higher in breast-fed than formula-
1,2
fed infants, independently of
ln leptin (ng/ ml)

0,8
anthropometric measurements
0,6

0,4
Females have a higher serum
leptin concentration than males
0,2
F M F M
0
1
BF FF

Savino F et al. Acta Paediatr 2005; 94: 531-7

With a larger sample,
sample, we confirmed that breast-
breast-fed infants
(n=38) have higher leptin levels than formula-fed
formula-fed ones (n=44)

Also, we observed that leptin levels were higher in breast-fed than In another study we evaluated the relationship between maternal
in formula-fed infants, independently of anthropometric BMI and serum leptin concentrations in infants in the first year of
measurements. Further, we have observed gender differences with life. We found a positive correlation between infant serum leptin
higher leptin levels in females than in males. Later, with a larger concentration and maternal BMI in breast-fed infants, but not in
sample size, we confirmed these observations. formula-fed infants. So maternal adiposity is a factor that might
affect the leptin levels in human milk.
2005: Petridou E et al. reported that formula-fed
formula-fed newborns have
higher serum leptin concentrations than breast-
breast-fed ones*
ones*
Leptin levels in breast-
breast-fed infants
Savino F et al. Clinical Endocrinology 2006;
2006; 64:596
64:596601

Difficult to evaluate the influence of the kind of feeding on

serum leptin concentration after only a few days of life (up to 5
days)
days)
As leptin secretion is pulsatile,
pulsatile, it is important to determine
serum leptin values at the same time in all infants (They
(They did not
specify the time of collection of the serum assay)
assay)**
Garnett SP et al. The art and science of regression
modelling;
modelling; methods for building valid models to explore
hormone and body composition interactions
interactions Ped Endocrinol
Rev 2005 it is not clear if assumptions for regression are met
so that spurious associations are not generated
* Petridou E et al. Clin Endocrinol 2005
** Weigle DS et al. Am J Clin Nutr 2005

But, to our surprise, Petridou and colleagues reported in 2005 that

formula-fed newborns have higher serum leptin concentrations Another hormone more recently discovered in 1999 is ghrelin.
than breast-fed ones. We commented on this paper some months Human ghrelin stimulates the release of growth hormone from the
later, pointing out that it is difficult to evaluate the influence of the pituitary working through the G protein coupled receptor. There
kind of feeding on serum leptin concentration after only a few are two types of receptors.
days of life, up to five days. Further, as leptin secretion is
pulsatile, it is important to determine serum leptin values at the
same time in all infants. In our study, we performed our Secretion
evaluation in the fasting period. The Petridou paper did not
specify the time of collection of the serum sample. Further, leptin Mainly produced
levels do not follow a normal distribution curve, which makes the in the stomach (in the oxyntic
interpretation more difficult. Our statistical analyses included mucosa) by enteroendocrine
regression analyses to eliminate spurious associations. X/A-like
X/A-like cells

2 forms of human ghrelin

NONACYLATED ACYLATED

Cardiovascular and Acylation is

antiproliferative essential for
effects endocrine
activity

Ghrelin, Leptin and IGF-I Levels in Breast-Fed Infants Francesco Savino

5
The secretion is mainly produced in the stomach by the
enteroendocrine X/A-like cells. There are two forms of human
ghrelin, acylated and nonacylated. The acylated form is the active
form that is essential for endocrine activity.
As concerns appetite regulation, ghrelin stimulates NPY/AgRP
neurons in the arcuate nucleus of the hypothalamus. These are
implicated in the central control of meal initiation because their
expression increases at times of maximal spontaneous feeding. So
ghrelin has orexigenic action.

Ghrelin also is secreted in a pulsatile manner, with a nocturnal

increase. The most important factor in the regulation of ghrelin This year two studies were published showing that ghrelin is
secretion is feeding. Ghrelin increases during fasting, (preprandial present in breast milk. Aydin reported the presence of ghrelin in
rise) and decreases after food intake (postprandial fall). colostrum, transitional and mature milk at levels lower than those
typically found in plasma. So milk ghrelin probably comes from
the plasma? More recently, Kierson showed that ghrelin levels are
Functions higher in whole than skim milk and that breast milk ghrelin levels
are higher than plasma levels. So ghrelin in breast milk is likely
Tumor synthesized and secreted from the breast? These data are all that
we have currently.
Brain
Heart

INSULIN LIKE GROWTH FACTOR I

Pituitary
Energy Insulin-
Insulin-like growth factor-1 (IGF-I) is the primary mediator of
Balance growth hormone (GH) effects
Member of a superfamily of related insulin-
insulin-like hormones
Stomach
It is a 70-amino acid single chain polypeptide;
polypeptide;
it consists of 4 domains (A,B,C,D)
Pancreas
IGF-I gene consists of 6 exons and 5
introns on chromosome 12
Van Der Lely AJ. et al. Endocrine Reviews 2004
75% of circulating IGF-I is produced by the LIVER

Functions are many, but as concerns our topic, energy balance, A family of six high-affinity
high-affinity IGF-binding
IGF-binding proteins (IGFBP-1 through
ghrelin influences energy metabolism and glucose metabolism. IGFBP-6) coordinate and regulate the biological activity of IGF

IGF-I levels decrease with sustained fasting and poor nutritional

status, but are unaffected by recent food intake

As concerns insulin like growth factor-I, IGF-1 is a hormone

produced by the liver. IGF-1 levels decrease with sustained
fasting and poor nutritional status but are unaffected by recent
food intake.

Milk, Hormones & Human Health October, 2006

6
 We performed a cross-sectional study in order to evaluate IGF-1 in
IGF-I receptor breast-fed and formula-fed infants. We found a positive
Type I IGF receptor (IGF-IR
(IGF-IR)) is a glycoprotein that transmits correlation between IGF-1 and zeta (Z) score for weight, BMI, and
IGF binding to a highly integrated intracellular signaling tricipital skin-fold thickness. So we hypothesize that there is a
system programming of the IGF-1 axis during infancy. Lower IGF-1
Promotion of intrinsic tyrosine kinase activity levels in breast-fed infants during the breast-feeding period re-sets
that phosphorylates the insulin receptor
substrates (IRS-1
(IRS-1 to IRS-4),
IRS-4), with the activation of
the pituitary due to less feedback, resulting in higher IGF-1 levels
two main downstream signaling cascades:
cascades: and thereby higher growth velocity later in childhood. Later
MAPK and phosphatidylinositol 3 kinase (PI3K(PI3K)) speakers will talk about this.

Functions

It plays an important role in both

embryonic and postnatal growth

IGF-I levels in humans correlate

with body size

BF infants:
infants:
The IGF-1 receptor plays an important role in both embryonic and higher leptin
postnatal growth. IGF-1 levels in humans correlate with body levels
size.
lower ghrelin
levels
IGF-I and milk lower IGF-I
levels
Klagsburn was the first to show that human milk contained than FF ones
growth factors that stimulated the growth of cells in culture*
culture*

Baxter et al.
al. demonstrated the presence of IGF-I in human In a more recent paper, we focused our attention on all three
milk ** hormones, and found that breast-fed infants have higher leptin
levels, lower ghrelin levels, and lower IGF-1 levels than formula-
Its levels are several-
several-fold higher in colostrum than in fed ones.
mature milk and they decrease precipitously in the first few
days of lactation

Also IGFBP have been identified in human milk

In our study we observed a
negative correlation
*Klagsburn M Proc.
Proc. Natl.
Natl. Acad.
Acad. Sci. U.S.A. 1978
between ghrelin and leptin
**Baxter RC et al. Clin.
Clin. Endocrinol.
Endocrinol. & Metab.
Metab. 1984
(=-0.1205; p<0.04)

Also, IGF is present in human milk. Klagsburn was the first to

show that human milk contained growth factors that stimulated the
growth of cells in culture. Baxter demonstrated the presence of
IGF-1 in human milk. Its levels are several-fold higher in Decreased leptin
colostrum than in mature milk and they decrease precipitously in secretion allows
the first few days of lactation. Also, IGF binding proteins stimulation of NPY by
(IGFBP) have been identified in human milk. ghrelin to induce
feeding

Further, we observed a negative correlation between ghrelin and

leptin. So a decrease in leptin secretion allows stimulation of NPY
neurons by ghrelin to induce feeding.

Ghrelin, Leptin and IGF-I Levels in Breast-Fed Infants Francesco Savino

7
 Ghrelin, energy balance,
balance, and weight in infants:
infants:
the chicken or the egg?
egg?
Philipps A.F. JPGN 2005

Do postnatal changes in ghrelin levels precede

changes in appetite or follow them?
them?

Examination of circulating blood ghrelin

concentrations may offer an insight into the fine-tuning
fine-tuning
of the coordination between dietary intake,
intake, energy
balance and growth factor modulation of somatic
growth in the first years of life

In a more recent paper, we tried to evaluate the correlation
between ghrelin, motilin, and insulin concentration in healthy term
infants in the first months of life in order to focus attention on the
relation of these factors to fasting time and anthropometry. We
observed that only ghrelin and motilin have a significant direct
correlation with fasting time. We don't know why we didnt find
any correlation with insulin, but speculate that it is because we
evaluated insulin preprandially, not after a meal.
And Anthony Philipps, who is here with us today, commented on
this paper in a very interesting editorial, asking, is ghrelin, energy
balance, and weight in infants, the chicken or the egg? We don't
know. Do postnatal changes in ghrelin levels precede changes in
appetite or follow them? Examination of circulating blood ghrelin
concentrations may offer an insight into the fine-tuning of the
coordination between dietary intake, energy balance, and growth
factor modulation of somatic growth in the first years of life.

Breast-
Breast-feeding and formula-feeding
formula-feeding::
effects on growth

Dewey KG et al. Pediatrics 1992:

1992:
Breast-
Breast-fed (BF) and formula-fed
formula-fed
(FF) infants have similar weight
gain in the first 3 months of life,
life,
but BF infants gain less rapidly
Ghrelin concentrations directly during the remainder of the first
correlated with age,
age, weight and year
length at time of collection in both
BF and FF infants
Butte et al. Pediatrics 2000:
2000: early feeding mode affects
Weight gain from birth correlated
growth and body composition;
composition; they observed lower fat free
negatively with serum ghrelin
mass and higher fat mass and percentage of fat mass in BF
levels in the BF group but not in
than in FF infants aged 3-9 months
the FF group

Evaluating the serum ghrelin concentration and weight gain in
healthy term infants in the first year of life, we observed that
ghrelin concentration directly correlates with age, weight and
length at the time of serum sample collection in both breast and
formula-fed infants. But weight gain from birth correlated
negatively with serum ghrelin levels in the breast-fed group, but
not in the formula-fed group.
But we know that breast-feeding and formula feeding can modify
the amount of growth. Dewey reported that breast-fed and
formula-fed infants may have similar weight gain in the first three
months of life, but the breast-fed infants gained less rapidly during
the remainder of the first year. Butte showed that early feeding
mode affects growth and body composition. She observed lower
fat free mass and higher fat mass and percentage of fat mass in
breast-fed than in formula-fed infants age 3 to 9 months.

Milk, Hormones & Human Health October, 2006

8
 Two recent meta-analyses, both independently performed, support
a protective effect of breast-feeding as compared with formula
Formula feeding is associated with
feeding on long-term overweight risk in children.
higher weight gain and length gain than
breastfeeding during infancy, particularly
after three months of age Duration of Breastfeeding and Risk of Overweight:
Overweight:
A Meta-Analysis
Meta-Analysis
Harder T. et al. Am J Epidemiol 2005

J Pediatr 2004;145:600-5

A dose-response relation between formula intake and both

length and weight gain has been demostrated
The 3 to 6 month interval is when these effects are Breast feeding up to 9 months is inversely associated
greatest with overweight risk,
risk, showing a dose-response
dose-response
relationship.
relationship.
This relationship strongly suggests causality of
So formula feeding is associated with a higher weight gain than associations,
associations, as it also does in epidemiologic studies
breast-feeding during infancy, particularly after three months of
age. A dose-response relationship between formula intake and
both length and weight has been demonstrated. The three to six
month interval is when these effects are greatest. And the duration is very interesting. Breast-feeding for up to 9
months is inversely associated with overweight risk, showing a
Protective effect of BF against obesity in childhood
dose response relationship. This relationship strongly suggests
causality in the associations, as it also does in epidemiologic
Breast feeding has positive health effects during breast feeding studies.
period,
period, such as protection against infectious diseases and long-
term effects on development and risk of later diseases

A large number of
studies show a small
but consistent
protective effect of
breast feeding
against risk of
obesity

A major limitation of most studies is that they are

observational, wherefore residual confounding and reverse
causality can never be completely ruled out

We also have to take into account the protective effect of breast-

feeding against obesity. An increasing number of papers have
been published about the protective role of breast-feeding against
obesity. But there are some limitations in these studies.
In conclusion, we observed that breast-fed infants have different
ghrelin, leptin, and IGF-1 levels in comparison with formula-fed
ones. These hormones may be involved in the regulation of
Effect of infant feeding on the risk of growth and development in neonatal age and infancy and may
obesity in childhood:
childhood: a quantitative
review of published evidence.
evidence. influence the programming of energy balance regulation in
Owen CG et al. Pediatrics 2005 childhood and adulthood. The question of whether breast milk
hormone synthesis and action are reflected by peripheral blood
OR: 0.87 concentrations in the neonate and infant remains open to debate
and further investigation.
Breast feeding and the risk of obesity and related metabolic
diseases in the child.
child. OR: 0.75 DISCUSSION:
Plagemann A. et al. Metab Syndr 2005

Both meta-analyses
meta-analyses independently performed support a
DR. NEVILLE: I have always thought that the decrease in the rate
protective effect of breast feeding,
feeding, as compared with formula of weight gain after the first three months in breast-fed infants
feeding,
feeding, on long-term
long-term overweight risk in children.
children. reflected a change in appetite, on the basis of no evidence, but it
always seemed like a good idea. The question is, of any of these
Differences between meta-analyses
meta-analyses on breastfeeding and obesity support factors which may or may not be present in formula, if you had to
causality of the association.
association. Pediatrics vol. 117 no. 3 march 2006
guess, which one would you think might be responsible?

Ghrelin, Leptin and IGF-I Levels in Breast-Fed Infants Francesco Savino

9
DR. SAVINO: Yes, in fact, it is a very complex topic. More
recently, new cytokines, new hormones, new proteins,
adiponectin, for example, have been identified in milk that suggest
other compounds are responsible. In my opinion, the issue is not
that these mediators are present in human milk but rather, the
quantity of protein that is present in formula compared with
human milk may be determinant of some of these differences.

DR HAN: That was an interesting summary of a lot of thoughts

and findings. I just want to make a comment that I think most of
us believe that whatever you see in the infant or the child blood in
terms of IGF or ghrelin or leptin is probably endogenous and not
exogenous, right?

DR. SAVINO: That is a very interesting question. Our data,

particularly in the first month of life, are based on similar weight
and body mass index among infants. So we have to expect that
leptin was the same in the first month if the infant has the same
weight and body mass index. However, further analyses among
infants with different body composition also don't show any
differences in leptin levels. So if there are no differences in leptin
levels among different body composition parameters like weight, I
hypothesize that the leptin levels observed in the first month come
from the breast milk, as well as endogenous sources.

Milk, Hormones & Human Health October, 2006

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