Early Human Development 90 (2014) 93–96
Contents lists available at ScienceDirect
Early Human Development journal homepage: www.elsevier.com/locate/earlhumdev
Symptoms of eating disorders and feeding practices in obese mothers Vincenzo Zanardo a,⁎, Gianluca Straface a, Barbara Benevento a, Irene Gambina b, Francesco Cavallin b, Daniele Trevisanuto b a b
Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy Department of Pediatrics, University of Padua School of Medicine, Padua, Italy
a r t i c l e
i n f o
Article history: Received 27 September 2013 Received in revised form 12 December 2013 Accepted 18 December 2013 Keywords: The Eating Disorders Inventory, EDI-2 Breastfeeding Weaning Gestational obesity
a b s t r a c t Background: The potential that obesity in pregnancy has to affect symptoms associated with eating disorders and breastfeeding is unclear. Aim: This study analyzed symptoms of eating disorders and breastfeeding practices in obese mothers. Study design: Prospective, case–control study. Subjects: Participants included 25 obese (BMI N 30 kg/m2) and 25 normal-weight puerperae, matched for parity and delivery route. Outcome measures: The participants completed the Eating Disorders Inventory (EDI-2), investigating cognitive, emotional, and behavioral symptoms of eating disorders before they were discharged from the maternity hospital and later participated in telephone interviews concerning breastfeeding practices which were classified according to WHO definitions. Results: Although none of the scores fell in the pathological range, the obese mothers had more and more pronounced symptoms of eating disorders in all EDI-2 subscales with respect to normal-weight mothers. They had, in particular, significantly higher scores in body dissatisfaction (p b .0001), ineffectiveness (p = .004), interoceptive awareness (p = .005), and maturity fear (p = .007). Finally, while breastfeeding practices were similar in the two groups, the obese mothers were more likely to maintain full breastfeeding at 6 months (20 vs 8%) and their tendency to postpone weaning was found to be significant (p b .04). Conclusions: While the obese mothers studied have more pronounced symptoms of eating disorders with respect to their normal-weight counterparts, they tended to maintain breastfeeding longer, postponing weaning. © 2013 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Obesity is a growing global problem [1]. Statistics on obesity in pregnant women in the United States report that approximately 18.5% to 38% of that population are obese, which makes it one of the country's most frequent high-risk obstetric situations [2]. A recent Australian study reported that 34% of that nation's pregnant women were overweight or obese and that obese puerperae had increased adverse maternal and neonatal outcomes, resulting in higher obstetric care costs [3]. As the prevalence of maternal obesity has risen dramatically in recent years and obesity is a problem that crosses generations, prevention has become an urgent priority [4]. A number of studies have found lower breastfeeding rates in obese women with respect to their normal-weight counterparts [5–7], and some have hypothesized that the increased use of formula milk will lead to a greater risk of obesity in childhood [8,9]. Some researchers have attributed the former to physiological causes, such as delayed lactogenesis [10] and/or lower prolactin response [11]. These biological ⁎ Corresponding author at: Department of Pediatrics, Padua University, Via Giustiniani, 3 35128 Padua, Italy. Tel.: +39 049 8213571; fax: +39 049 8213509. E-mail address: [email protected] (V. Zanardo). 0378-3782/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.earlhumdev.2013.12.006
effects are, however, strongly influenced by confounding, in which maternal factors (e.g., parental obesity and socioeconomic status) or psychological and behavioral factors are of particular importance to feeding decisions [7]. During pregnancy, conflicts about body changes, alterations in roles, additions of responsibility, and concerns about a woman's own mothering abilities are prevalent. Many of these concerns are also directly linked to puerperium, a period during which previously dormant psychological issues such as fears about physical changes, role adaptation, psychosocial stress, and mothering abilities come to the surface also of great importance to the psychology of lactation [12]. Despite the facts that eating disorders affect a large percentage of adolescent females [13], the number of obese women in child-bearing age is climbing [14], and pregnancy is a period of important developmental changes, little is known about how obesity in pregnancy can affect breastfeeding. To date, no published study has examined this issue from the perspective of obese puerperae and no studies have analyzed eating disorder symptoms and breastfeeding success in this population. The aim of this study was, then, to examine the relationship between maternal obesity, symptoms of eating disorders, and breastfeeding initiation and duration.
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V. Zanardo et al. / Early Human Development 90 (2014) 93–96
2. Methods 2.1. During a recent longitudinal prospective study to evaluate body image and breastfeeding practices in obese mothers [15], we planned additional analyses to determine if maternal obesity is associated with symptoms of eating disorders
practice in our center, all of the participants were encouraged to breastfeed even while they were still in the delivery room during the first minutes after birth. Those mothers agreeing to the rooming-in regimen offered by the hospital were never separated from their newborns who were breast-fed ad libitum and weighed once a day. Those mothers who preferred to use formula feeding offered their infants a bottle-fed formula following a 3-hour schedule. Infant feeding data were recorded in accordance with the definitions of the World Health Organization (exclusive breastfeeding is defined as only maternal milk and nothing else; complementary breastfeeding is defined as a combination of breast milk and formula; and exclusive formula feeding is defined as offering exclusively bottle-fed formula) [19]. Feeding practices during the hospital stay were collected directly from the patients themselves and from their medical records. Breastfeeding patterns after discharge from the hospital and weaning data (the transition from breast-feeding or formula milk to semi-solid foods) were collected from the mothers by a trained professional during the follow-up telephone interviews that were held one, three, and six months later. At each interview, the mothers were asked to indicate with a yes/no response if they were still breastfeeding. At the 3- and 6-month interviews the mothers were queried if and when they had begun to wean their infants. On the basis of the mother's answers of yes or no, we defined the end of breastfeeding and beginning of weaning as 1, 3 or 6 months. This and all other pertinent information were collected and used in the following analyses.
Twenty-five consecutive, healthy, full-term, obese (BMI N 30 kg/m2) pregnant women presenting at a tertiary medical center between January and June 2011 were studied. The control group consisted of 25 healthy, full-term, normal-weight pregnant women matched for parity and delivery route. Every obese woman who gave birth to a full-term infant and the first normal-weight woman who gave birth afterwards were considered eligible. Inclusion criteria for both the study and control groups were: Italian-speaking women older than 18 who were not being treated for psychological disorders at the time of recruitment and who gave birth after at least 37 weeks of gestation to healthy, single infants without medical complications. Of the 81 women who were initially contacted, 50 met the inclusion criteria and were recruited for the study (Table 1). This prospective, case–control study is the outcome of the collaborative efforts of the Department of Pediatrics and the Department of Obstetrics and Gynecology of the University of Padua Medical Center. Granted by the approval of the Medical Faculty's ethics committee, the study was carried out in accordance with the Declaration of Helsinki. After being informed about the study's aims and methods, the participants (obese and normal-weight women) signed informed consent forms. All of the participants were assessed during their hospital stay, usually one day before they were discharged and generally three to four days after birth. At that time the participants were asked to fill out the Eating Disorders Inventory, (EDI-2; Psychological Assessment Resources, Inc., Odessa, FL 1968) [16,17] and their clinical and demographic characteristics were reviewed. The EDI is a self-report questionnaire used to assess cognitive, emotional, and behavioral symptoms of eating disorders. The EDI-1 comprises 64 questions, divided into eight subscales: drive for thinness, ineffectiveness, body dissatisfaction, interpersonal distrust, bulimia, perfectionism, maturity fears, and interoceptive awareness. The EDI-2, the edition of the inventory that was used in this study, included 27 additional items and 3 subscales: impulse regulation, social insecurity, and asceticism. All the subscales of the EDI-2 were used in this study. The inventory employs a 6-point Likert response scale (ranging from ‘always’ to ‘never’, rated 0–3). The score is calculated by summing the scores for each sub-scale. Higher scores are indicative of more symptoms [18]. The EDI-2 has high test–retest reliability (r = 0.75 to 0.94), good internal consistency (Cronbach's α = 0.73 to 93), and has been used extensively [18]. All of the participants taking part in the study were given information about the relationship between gestational obesity, symptoms predictive of eating disorders, and breastfeeding success. As is the normal
While the obese mothers were free of psychopathology, they showed more frequent symptoms of eating disorders on all EDI-2 subscales with respect to their normal-weight counterparts. The obese mothers had, in fact, significantly higher scores in body dissatisfaction (P b .0001), ineffectiveness (P = .004), interoceptive awareness (p = .005), and maturity fear (p = .007) (Table 1). Finally, while the breastfeeding practices were similar in the two groups, the obese mothers were more likely to maintain full breastfeeding even 6 months after birth (20 vs 8%) and their tendency to postpone weaning was found to be significant (p b .04) (Table 2).
Table 1 Eating disorder inventory-2 subscale scores (mean ± SD).
Table 2 Breastfeeding and weaning practices in obese and normal-weight mothers.
Mothers
Obese
EDI-2 subscale Drive for thinness Bulimia Body dissatisfaction Ineffectiveness Perfectionism Interpersonal distrust Interoceptive awareness Maturity fear Asceticism Impulse regulation Social insecurity
3.24 1.24 9.4 4.36 1.48 2.92 1.36 5.04 3.4 2.24 4.6
± ± ± ± ± ± ± ± ± ± ±
2.6 3.73 4.3 0.82 5.51 1.48 1.61 3.58 1.32 2.66 3.17
2.2. Statistical analyses The patients' weights (in kg) were converted into BMI units to facilitate the comparison between groups. A descriptive analysis was used to construct a qualitative evaluation of the participants' clinical data, their responses to the questionnaires, and their breastfeeding outcomes. Continuous variables were expressed as means and standard deviation (SD). Categorical data were compared using Fisher's exact test, while continuous data were compared using the Student's test. A p-value less than .05 was considered significant. Statistical analysis was performed using R 2.12 software. 3. Results
Normal-weight
p-Value
Mothers
Obese
Normal-weight 25
.08 .08 .0001 .004 .17 .06 .005 .007 .91 .008 .85
N. Breastfeeding at discharge, N (%) Exclusive Complementary Formula Breastfeeding discontinuation, N (%) 1 month 3 months 6 months Weaning age (month), N(%) 3 months 6 months
25
1.36 0.48 3.28 2.12 1 2 0.6 2.72 3.28 0.88 4.12
22 (88) 3 (2) 0
18 (72) 4 (16) 3 (12)
1 [4] 1 [4] 23 (92)
2 [8] 3 [12] 20 (80)
7 [28] 18 (72)
1 [4] 24 (96)
± ± ± ± ± ± ± ± ± ± ±
1.7 0.92 4.24 3.66 1.35 2.99 1.5 2.42 2.07 1.69 4.85
p-Value .27
.50
.04
V. Zanardo et al. / Early Human Development 90 (2014) 93–96
4. Discussion It has been seen that a wide range of physiopathological, sociocultural, behavioral, and psychological variables affect a woman's decision and ability to breastfeed successfully [20]. The association that has been noted between maternal obesity and low breastfeeding rates is a matter of public health concern because obesity is rising in women of reproductive age and the use of formula milk has been found to be associated with a greater risk of obesity in childhood [21,22]. Our study focusing on eating disorder symptoms and breastfeeding practices in obese puerperae living in an industrial area of NorthEastern Italy found that obese mothers are more likely to maintain a full breastfeeding regimen at 6 months and to postpone weaning their infants despite greater body image dissatisfaction, ineffectiveness, interoceptive awareness, and maturity fears found on their EDI-2 scores. These symptoms are indicative of a lower sense of control and adequacy in their lives and denote insecurity, relationship incompetence, ineffectiveness, and an incapability of asking and obtaining help from the others [23]. Some studies have reported that obese puerperae are more likely to encounter difficulties in their efforts to breastfeed and that they breastfeed for shorter periods of time with respect to their normalweight counterparts [5,24,25]. Our data do not support findings that obese puerperae are less likely to initiate breastfeeding and more likely to cease breastfeeding sooner [5]. Our findings may, nevertheless, be biased by the particular features of our study population which was characterized by low parity, elevated median age, high educational attainment, income, and occupational level, and stable social/marital status [15]. It is also possible that obese pregnant mothers in the Western Hemisphere who in any case receive some kind of health care and medical attention are prolonging breastfeeding and delaying weaning their offspring in the attempt to prevent obesity in their children [26]. While any mechanism by which being overweight or obesity may have negative effects on lactational performance has yet to be clearly defined, its origin is likely multifactorial. A number of biological factors have been identified: increasing prepregnant BMI has, for example, been associated with delayed lactogenesis, [10] and prepregnant obese or overweight women have a lower prolactin response to suckling in the early postpartum period [6] which is associated with shortened duration of breastfeeding and may contribute to poor lactational performance in this population. Although poorly defined and understood, increasing evidence indicates that psychological and behavioral factors are also important in obese women [26]. It is unclear from the literature data available if pregnancy exerts any influence on eating disorders and research studying long-term outcomes in these children is scarce. Some studies have reported a decline in symptoms, while others a heightened symptomatology [29]. It has, nevertheless, been found that when an eating disorder is present during a pregnancy, there is greater risk of a lower maternal-fetal attachment, [30] and the difficulties encountered in maintaining breast-feeding are increased [31]. A small study focusing on obese formula-feeding mothers reported, in fact, that these mothers spent less time interacting with their infants over a 24 hour period than non-obese counterparts [32]. It has also been demonstrated that the children of women with past or current eating disorders are exposed to less eating behavior socialization during early childhood. Those children also weigh less in the toddler years than control children [33]. In a recent review by Lefebvre and John [27], the authors hypothesized that there are protective benefits of breastfeeding on childhood obesity. Even if these benefits are difficult to prove due to confounding variables, current medical recommendations based on scientific evidence and the WHO agree that breastfeeding is superior to formula feeding for infants. However, this study has some limitations. First, the present study focuses on obese women using a case–control design to prospectively compare breastfeeding practices and symptoms of eating disorders at
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the end of a full-term pregnancy with no distinction being made with regard to the time of obesity insurgence. Second, no attempt was made to ascertain if values of body dissatisfaction changed during the 6 month postpartum study period or if the mothers noted any improvement in their disorderly eating behavior tends in conjunction with physiological post partum and post lactation weight loss, and/or by standard weight loss programs. Third, the study did not take into consideration determinants of both gestational obesity and eating disorder symptoms (e.g., family history of obesity, age at onset of obesity, critical comments received in the past on shape and weight, attitudes toward exercise, obesity-related comorbidities). In conclusion, breastfeeding behavior is multifactorial with wide range of socio-cultural and physiological variables affecting a woman's decision and ability to breastfeed successfully. Our study findings have indicated that obese puerperae present more pronounced symptoms of eating disorders and tend to postpone weaning. Further studies controlling for confounding variables and exploring the connection between obesity, breastfeeding patterns, and childhood/adulthood obesity are, of course, warranted. Conflict of interest All authors disclose any financial and personal relationships with other people or organizations that could inappropriately influence their work. References [1] World Health Organization. Obesity: preventing and managing the global epidemic: report of a WHO consultation. World Health Organ Tech Rep Ser 2000;894:1–253. [2] Galtier-Dereure F, Boegner C, Bringer J. Obesity and pregnancy: complications and cost. Am J Clin Nutr 2000;71:1242S–8S. [3] Callaway LK, Prins JB, Chang AM, McIntyre HD. The prevalence and impact of overweight and obesity in an Australian population. Med J Aust 2006;184:56–9. [4] Michels KB, Willett WC, Graubard BI, Vaidya RL, Cantwell MM, Sansbury B, et al. A longitudinal study of infant feeding and obesity throughout life course. Int J Obes 2007;13 1078–1075. [5] Donath SM, Amir LH. Does maternal obesity adversely affect breastfeeding initiation and duration? J Paediatr Child Health 2000;36:482–6. [6] Rasmussen KM. Association of maternal obesity before conception with poor lactation performance. Rev Nutr 2007;27:103–21. [7] Amir LH, Donath S. A systematic review of maternal obesity and breastfeeding intention, initiation and duration. BMC Pregnancy Childbirth 2007;4:7–9. [8] Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of breastfeeding and risk of overweight: a meta-analysis. Am J Epidemiol 2005;162:397–403. [9] Owen CG, Martin RM, Whincup PH, Davey Smith G, Cook DG. Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published evidence. Pediatrics 2005;115:1367–77. [10] Chapman DJ, Perez-Escamilla R. Identification of risk factors for delayed onset of lactation. J Am Diet Assoc 1999;99:450–4. [11] Rasmussen KM, Kjolhede CL. Prepregnant overweight and obesity diminish the prolactin response to suckling in the first week postpartum. Pediatrics 2004;113: e465–71. [12] Da Costa D, Larouche J, Dritsa M, Brender W. Psychosocial correlates of prepartum and postpartum depressed mood. J Affect Disord 2000;59:31–40. [13] Hamel AE. Body-related social comparison and disordered eating among adolescent females with an eating disorder, depressive disorder, and healthy controls. Nutrients 2012;4:1260–72. [14] Heslehurst N, Ells LJ, Batterham A, Wilkinson J, Summerbell CD. Trends in maternal obesity incidence rates, demographic predictors, and health inequalities in 36821 women over a 15-year period. BJOG 2007;114:187–94. [15] Zanardo V, Gambina I, Cavallin F, Straface G, Trevisanuto D. Body image and breastfeeding practices in obese mothers. Eat Weight Disord 2013 [in press]. [16] Rizzardi M, Trombini E, Trombini G. Eating disorder inventory 2 versione Italiana, 1995, Firenze. Odessa, FL: Psychological Assessment Resources, Inc.; 1995. [17] Garner DM, Olmstead MP, Polivy J. Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. Int J Eat Disord 1983;2:15–34. [18] American Psychiatric Association. Diagnostic and statistical manual of mental disorders4th ed. 1994 [Washington DC]. [19] World Health Organisation. Indicators for assessing breast-feeding practices. Geneva, Switzerland, Publication WHO/CDD/SER/91; 1991 14. [20] Dewey KC, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics 2003;112:607–19. [21] Johnson DB, Gerstein D, Evans AE, Woodward-Lopez G. Preventing obesity: a life cycle perspective. J Am Diet Assoc 2006;106:97–102.
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[22] Campos P, Saguy A, Ernsberger P, Eric OE, Gaesser C. The epidemiology of overweight and obesity: public health crisis or moral panic? Int J Epidemiol 2006;35:55–60. [23] Broussard B. Psychological and behavioral traits associated with eating disorders and pregnancy: a pilot study. J Midwifery Womens Health 2012;57:61–6. [24] Sarwer DB, Wadden TA, Foster GD. Assessment of body image dissatisfaction in obese women: specificity, severity, and clinical significance. J Cons Clin Psychol 1998;66:651–4. [25] Rasmussen KM. Obesity stigmatization and coping: relation to mental health symptoms, body image, and self-esteem. Int J Obes Relat Metab Disord 2007;23:221–30. [26] Kugyelka JG, Rasmussen KM, Frongillo EA. Maternal obesity is negatively associated with breastfeeding success among Hispanic but not black women. J Nutr 2004;134:1746–53.
[27] Lefebvre CM, John RM. The effect of breastfeeding on childhood overweight and obesity: a systematic review of the literature. Am Assoc Nurse Pract Jul 12 2013. http://dx.doi.org/10.1002/2327-6924.12036. [28] Torgersen L, Ystrom E, Haugen M, Meltzer HM, Von Holle A, Berg CK, et al. Breastfeeding practice in mothers with eating disorders 2010;6:243–52. [29] Franco D, Valton BE. Pregnancy and eating disorders: a review and clinical implications. Int J Eat Disord 1993;1:41–8. [30] Conti Abraham S, Taylor A. Eating behavior and pregnancy outcome. J Psychosom Res 1998;44:65–477. [31] Foster SF, Slade P, Wilson K. Body image, maternal and fetal attachment and breast feeding. J Psychosom Res 1996;4:181–4. [32] Rising R, Lifshitz F. Relationship between maternal obesity and infant feedinginteractions. Nutr J 2005;4:17–30. [33] Waugh E, Bulik CM. Offspring of women with eating disorders. Int J Eat Disord 1999;25:123–33.
Contents lists available at ScienceDirect
Early Human Development journal homepage: www.elsevier.com/locate/earlhumdev
Symptoms of eating disorders and feeding practices in obese mothers Vincenzo Zanardo a,⁎, Gianluca Straface a, Barbara Benevento a, Irene Gambina b, Francesco Cavallin b, Daniele Trevisanuto b a b
Division of Perinatal Medicine, Policlinico Abano Terme, Abano Terme, Italy Department of Pediatrics, University of Padua School of Medicine, Padua, Italy
a r t i c l e
i n f o
Article history: Received 27 September 2013 Received in revised form 12 December 2013 Accepted 18 December 2013 Keywords: The Eating Disorders Inventory, EDI-2 Breastfeeding Weaning Gestational obesity
a b s t r a c t Background: The potential that obesity in pregnancy has to affect symptoms associated with eating disorders and breastfeeding is unclear. Aim: This study analyzed symptoms of eating disorders and breastfeeding practices in obese mothers. Study design: Prospective, case–control study. Subjects: Participants included 25 obese (BMI N 30 kg/m2) and 25 normal-weight puerperae, matched for parity and delivery route. Outcome measures: The participants completed the Eating Disorders Inventory (EDI-2), investigating cognitive, emotional, and behavioral symptoms of eating disorders before they were discharged from the maternity hospital and later participated in telephone interviews concerning breastfeeding practices which were classified according to WHO definitions. Results: Although none of the scores fell in the pathological range, the obese mothers had more and more pronounced symptoms of eating disorders in all EDI-2 subscales with respect to normal-weight mothers. They had, in particular, significantly higher scores in body dissatisfaction (p b .0001), ineffectiveness (p = .004), interoceptive awareness (p = .005), and maturity fear (p = .007). Finally, while breastfeeding practices were similar in the two groups, the obese mothers were more likely to maintain full breastfeeding at 6 months (20 vs 8%) and their tendency to postpone weaning was found to be significant (p b .04). Conclusions: While the obese mothers studied have more pronounced symptoms of eating disorders with respect to their normal-weight counterparts, they tended to maintain breastfeeding longer, postponing weaning. © 2013 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Obesity is a growing global problem [1]. Statistics on obesity in pregnant women in the United States report that approximately 18.5% to 38% of that population are obese, which makes it one of the country's most frequent high-risk obstetric situations [2]. A recent Australian study reported that 34% of that nation's pregnant women were overweight or obese and that obese puerperae had increased adverse maternal and neonatal outcomes, resulting in higher obstetric care costs [3]. As the prevalence of maternal obesity has risen dramatically in recent years and obesity is a problem that crosses generations, prevention has become an urgent priority [4]. A number of studies have found lower breastfeeding rates in obese women with respect to their normal-weight counterparts [5–7], and some have hypothesized that the increased use of formula milk will lead to a greater risk of obesity in childhood [8,9]. Some researchers have attributed the former to physiological causes, such as delayed lactogenesis [10] and/or lower prolactin response [11]. These biological ⁎ Corresponding author at: Department of Pediatrics, Padua University, Via Giustiniani, 3 35128 Padua, Italy. Tel.: +39 049 8213571; fax: +39 049 8213509. E-mail address: [email protected] (V. Zanardo). 0378-3782/$ – see front matter © 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.earlhumdev.2013.12.006
effects are, however, strongly influenced by confounding, in which maternal factors (e.g., parental obesity and socioeconomic status) or psychological and behavioral factors are of particular importance to feeding decisions [7]. During pregnancy, conflicts about body changes, alterations in roles, additions of responsibility, and concerns about a woman's own mothering abilities are prevalent. Many of these concerns are also directly linked to puerperium, a period during which previously dormant psychological issues such as fears about physical changes, role adaptation, psychosocial stress, and mothering abilities come to the surface also of great importance to the psychology of lactation [12]. Despite the facts that eating disorders affect a large percentage of adolescent females [13], the number of obese women in child-bearing age is climbing [14], and pregnancy is a period of important developmental changes, little is known about how obesity in pregnancy can affect breastfeeding. To date, no published study has examined this issue from the perspective of obese puerperae and no studies have analyzed eating disorder symptoms and breastfeeding success in this population. The aim of this study was, then, to examine the relationship between maternal obesity, symptoms of eating disorders, and breastfeeding initiation and duration.
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V. Zanardo et al. / Early Human Development 90 (2014) 93–96
2. Methods 2.1. During a recent longitudinal prospective study to evaluate body image and breastfeeding practices in obese mothers [15], we planned additional analyses to determine if maternal obesity is associated with symptoms of eating disorders
practice in our center, all of the participants were encouraged to breastfeed even while they were still in the delivery room during the first minutes after birth. Those mothers agreeing to the rooming-in regimen offered by the hospital were never separated from their newborns who were breast-fed ad libitum and weighed once a day. Those mothers who preferred to use formula feeding offered their infants a bottle-fed formula following a 3-hour schedule. Infant feeding data were recorded in accordance with the definitions of the World Health Organization (exclusive breastfeeding is defined as only maternal milk and nothing else; complementary breastfeeding is defined as a combination of breast milk and formula; and exclusive formula feeding is defined as offering exclusively bottle-fed formula) [19]. Feeding practices during the hospital stay were collected directly from the patients themselves and from their medical records. Breastfeeding patterns after discharge from the hospital and weaning data (the transition from breast-feeding or formula milk to semi-solid foods) were collected from the mothers by a trained professional during the follow-up telephone interviews that were held one, three, and six months later. At each interview, the mothers were asked to indicate with a yes/no response if they were still breastfeeding. At the 3- and 6-month interviews the mothers were queried if and when they had begun to wean their infants. On the basis of the mother's answers of yes or no, we defined the end of breastfeeding and beginning of weaning as 1, 3 or 6 months. This and all other pertinent information were collected and used in the following analyses.
Twenty-five consecutive, healthy, full-term, obese (BMI N 30 kg/m2) pregnant women presenting at a tertiary medical center between January and June 2011 were studied. The control group consisted of 25 healthy, full-term, normal-weight pregnant women matched for parity and delivery route. Every obese woman who gave birth to a full-term infant and the first normal-weight woman who gave birth afterwards were considered eligible. Inclusion criteria for both the study and control groups were: Italian-speaking women older than 18 who were not being treated for psychological disorders at the time of recruitment and who gave birth after at least 37 weeks of gestation to healthy, single infants without medical complications. Of the 81 women who were initially contacted, 50 met the inclusion criteria and were recruited for the study (Table 1). This prospective, case–control study is the outcome of the collaborative efforts of the Department of Pediatrics and the Department of Obstetrics and Gynecology of the University of Padua Medical Center. Granted by the approval of the Medical Faculty's ethics committee, the study was carried out in accordance with the Declaration of Helsinki. After being informed about the study's aims and methods, the participants (obese and normal-weight women) signed informed consent forms. All of the participants were assessed during their hospital stay, usually one day before they were discharged and generally three to four days after birth. At that time the participants were asked to fill out the Eating Disorders Inventory, (EDI-2; Psychological Assessment Resources, Inc., Odessa, FL 1968) [16,17] and their clinical and demographic characteristics were reviewed. The EDI is a self-report questionnaire used to assess cognitive, emotional, and behavioral symptoms of eating disorders. The EDI-1 comprises 64 questions, divided into eight subscales: drive for thinness, ineffectiveness, body dissatisfaction, interpersonal distrust, bulimia, perfectionism, maturity fears, and interoceptive awareness. The EDI-2, the edition of the inventory that was used in this study, included 27 additional items and 3 subscales: impulse regulation, social insecurity, and asceticism. All the subscales of the EDI-2 were used in this study. The inventory employs a 6-point Likert response scale (ranging from ‘always’ to ‘never’, rated 0–3). The score is calculated by summing the scores for each sub-scale. Higher scores are indicative of more symptoms [18]. The EDI-2 has high test–retest reliability (r = 0.75 to 0.94), good internal consistency (Cronbach's α = 0.73 to 93), and has been used extensively [18]. All of the participants taking part in the study were given information about the relationship between gestational obesity, symptoms predictive of eating disorders, and breastfeeding success. As is the normal
While the obese mothers were free of psychopathology, they showed more frequent symptoms of eating disorders on all EDI-2 subscales with respect to their normal-weight counterparts. The obese mothers had, in fact, significantly higher scores in body dissatisfaction (P b .0001), ineffectiveness (P = .004), interoceptive awareness (p = .005), and maturity fear (p = .007) (Table 1). Finally, while the breastfeeding practices were similar in the two groups, the obese mothers were more likely to maintain full breastfeeding even 6 months after birth (20 vs 8%) and their tendency to postpone weaning was found to be significant (p b .04) (Table 2).
Table 1 Eating disorder inventory-2 subscale scores (mean ± SD).
Table 2 Breastfeeding and weaning practices in obese and normal-weight mothers.
Mothers
Obese
EDI-2 subscale Drive for thinness Bulimia Body dissatisfaction Ineffectiveness Perfectionism Interpersonal distrust Interoceptive awareness Maturity fear Asceticism Impulse regulation Social insecurity
3.24 1.24 9.4 4.36 1.48 2.92 1.36 5.04 3.4 2.24 4.6
± ± ± ± ± ± ± ± ± ± ±
2.6 3.73 4.3 0.82 5.51 1.48 1.61 3.58 1.32 2.66 3.17
2.2. Statistical analyses The patients' weights (in kg) were converted into BMI units to facilitate the comparison between groups. A descriptive analysis was used to construct a qualitative evaluation of the participants' clinical data, their responses to the questionnaires, and their breastfeeding outcomes. Continuous variables were expressed as means and standard deviation (SD). Categorical data were compared using Fisher's exact test, while continuous data were compared using the Student's test. A p-value less than .05 was considered significant. Statistical analysis was performed using R 2.12 software. 3. Results
Normal-weight
p-Value
Mothers
Obese
Normal-weight 25
.08 .08 .0001 .004 .17 .06 .005 .007 .91 .008 .85
N. Breastfeeding at discharge, N (%) Exclusive Complementary Formula Breastfeeding discontinuation, N (%) 1 month 3 months 6 months Weaning age (month), N(%) 3 months 6 months
25
1.36 0.48 3.28 2.12 1 2 0.6 2.72 3.28 0.88 4.12
22 (88) 3 (2) 0
18 (72) 4 (16) 3 (12)
1 [4] 1 [4] 23 (92)
2 [8] 3 [12] 20 (80)
7 [28] 18 (72)
1 [4] 24 (96)
± ± ± ± ± ± ± ± ± ± ±
1.7 0.92 4.24 3.66 1.35 2.99 1.5 2.42 2.07 1.69 4.85
p-Value .27
.50
.04
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4. Discussion It has been seen that a wide range of physiopathological, sociocultural, behavioral, and psychological variables affect a woman's decision and ability to breastfeed successfully [20]. The association that has been noted between maternal obesity and low breastfeeding rates is a matter of public health concern because obesity is rising in women of reproductive age and the use of formula milk has been found to be associated with a greater risk of obesity in childhood [21,22]. Our study focusing on eating disorder symptoms and breastfeeding practices in obese puerperae living in an industrial area of NorthEastern Italy found that obese mothers are more likely to maintain a full breastfeeding regimen at 6 months and to postpone weaning their infants despite greater body image dissatisfaction, ineffectiveness, interoceptive awareness, and maturity fears found on their EDI-2 scores. These symptoms are indicative of a lower sense of control and adequacy in their lives and denote insecurity, relationship incompetence, ineffectiveness, and an incapability of asking and obtaining help from the others [23]. Some studies have reported that obese puerperae are more likely to encounter difficulties in their efforts to breastfeed and that they breastfeed for shorter periods of time with respect to their normalweight counterparts [5,24,25]. Our data do not support findings that obese puerperae are less likely to initiate breastfeeding and more likely to cease breastfeeding sooner [5]. Our findings may, nevertheless, be biased by the particular features of our study population which was characterized by low parity, elevated median age, high educational attainment, income, and occupational level, and stable social/marital status [15]. It is also possible that obese pregnant mothers in the Western Hemisphere who in any case receive some kind of health care and medical attention are prolonging breastfeeding and delaying weaning their offspring in the attempt to prevent obesity in their children [26]. While any mechanism by which being overweight or obesity may have negative effects on lactational performance has yet to be clearly defined, its origin is likely multifactorial. A number of biological factors have been identified: increasing prepregnant BMI has, for example, been associated with delayed lactogenesis, [10] and prepregnant obese or overweight women have a lower prolactin response to suckling in the early postpartum period [6] which is associated with shortened duration of breastfeeding and may contribute to poor lactational performance in this population. Although poorly defined and understood, increasing evidence indicates that psychological and behavioral factors are also important in obese women [26]. It is unclear from the literature data available if pregnancy exerts any influence on eating disorders and research studying long-term outcomes in these children is scarce. Some studies have reported a decline in symptoms, while others a heightened symptomatology [29]. It has, nevertheless, been found that when an eating disorder is present during a pregnancy, there is greater risk of a lower maternal-fetal attachment, [30] and the difficulties encountered in maintaining breast-feeding are increased [31]. A small study focusing on obese formula-feeding mothers reported, in fact, that these mothers spent less time interacting with their infants over a 24 hour period than non-obese counterparts [32]. It has also been demonstrated that the children of women with past or current eating disorders are exposed to less eating behavior socialization during early childhood. Those children also weigh less in the toddler years than control children [33]. In a recent review by Lefebvre and John [27], the authors hypothesized that there are protective benefits of breastfeeding on childhood obesity. Even if these benefits are difficult to prove due to confounding variables, current medical recommendations based on scientific evidence and the WHO agree that breastfeeding is superior to formula feeding for infants. However, this study has some limitations. First, the present study focuses on obese women using a case–control design to prospectively compare breastfeeding practices and symptoms of eating disorders at
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the end of a full-term pregnancy with no distinction being made with regard to the time of obesity insurgence. Second, no attempt was made to ascertain if values of body dissatisfaction changed during the 6 month postpartum study period or if the mothers noted any improvement in their disorderly eating behavior tends in conjunction with physiological post partum and post lactation weight loss, and/or by standard weight loss programs. Third, the study did not take into consideration determinants of both gestational obesity and eating disorder symptoms (e.g., family history of obesity, age at onset of obesity, critical comments received in the past on shape and weight, attitudes toward exercise, obesity-related comorbidities). In conclusion, breastfeeding behavior is multifactorial with wide range of socio-cultural and physiological variables affecting a woman's decision and ability to breastfeed successfully. Our study findings have indicated that obese puerperae present more pronounced symptoms of eating disorders and tend to postpone weaning. Further studies controlling for confounding variables and exploring the connection between obesity, breastfeeding patterns, and childhood/adulthood obesity are, of course, warranted. Conflict of interest All authors disclose any financial and personal relationships with other people or organizations that could inappropriately influence their work. References [1] World Health Organization. Obesity: preventing and managing the global epidemic: report of a WHO consultation. World Health Organ Tech Rep Ser 2000;894:1–253. [2] Galtier-Dereure F, Boegner C, Bringer J. Obesity and pregnancy: complications and cost. Am J Clin Nutr 2000;71:1242S–8S. [3] Callaway LK, Prins JB, Chang AM, McIntyre HD. The prevalence and impact of overweight and obesity in an Australian population. Med J Aust 2006;184:56–9. [4] Michels KB, Willett WC, Graubard BI, Vaidya RL, Cantwell MM, Sansbury B, et al. A longitudinal study of infant feeding and obesity throughout life course. Int J Obes 2007;13 1078–1075. [5] Donath SM, Amir LH. Does maternal obesity adversely affect breastfeeding initiation and duration? J Paediatr Child Health 2000;36:482–6. [6] Rasmussen KM. Association of maternal obesity before conception with poor lactation performance. Rev Nutr 2007;27:103–21. [7] Amir LH, Donath S. A systematic review of maternal obesity and breastfeeding intention, initiation and duration. BMC Pregnancy Childbirth 2007;4:7–9. [8] Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of breastfeeding and risk of overweight: a meta-analysis. Am J Epidemiol 2005;162:397–403. [9] Owen CG, Martin RM, Whincup PH, Davey Smith G, Cook DG. Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published evidence. Pediatrics 2005;115:1367–77. [10] Chapman DJ, Perez-Escamilla R. Identification of risk factors for delayed onset of lactation. J Am Diet Assoc 1999;99:450–4. [11] Rasmussen KM, Kjolhede CL. Prepregnant overweight and obesity diminish the prolactin response to suckling in the first week postpartum. Pediatrics 2004;113: e465–71. [12] Da Costa D, Larouche J, Dritsa M, Brender W. Psychosocial correlates of prepartum and postpartum depressed mood. J Affect Disord 2000;59:31–40. [13] Hamel AE. Body-related social comparison and disordered eating among adolescent females with an eating disorder, depressive disorder, and healthy controls. Nutrients 2012;4:1260–72. [14] Heslehurst N, Ells LJ, Batterham A, Wilkinson J, Summerbell CD. Trends in maternal obesity incidence rates, demographic predictors, and health inequalities in 36821 women over a 15-year period. BJOG 2007;114:187–94. [15] Zanardo V, Gambina I, Cavallin F, Straface G, Trevisanuto D. Body image and breastfeeding practices in obese mothers. Eat Weight Disord 2013 [in press]. [16] Rizzardi M, Trombini E, Trombini G. Eating disorder inventory 2 versione Italiana, 1995, Firenze. Odessa, FL: Psychological Assessment Resources, Inc.; 1995. [17] Garner DM, Olmstead MP, Polivy J. Development and validation of a multidimensional eating disorder inventory for anorexia nervosa and bulimia. Int J Eat Disord 1983;2:15–34. [18] American Psychiatric Association. Diagnostic and statistical manual of mental disorders4th ed. 1994 [Washington DC]. [19] World Health Organisation. Indicators for assessing breast-feeding practices. Geneva, Switzerland, Publication WHO/CDD/SER/91; 1991 14. [20] Dewey KC, Nommsen-Rivers LA, Heinig MJ, Cohen RJ. Risk factors for suboptimal infant breastfeeding behavior, delayed onset of lactation, and excess neonatal weight loss. Pediatrics 2003;112:607–19. [21] Johnson DB, Gerstein D, Evans AE, Woodward-Lopez G. Preventing obesity: a life cycle perspective. J Am Diet Assoc 2006;106:97–102.
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