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Rev Paul Pediatr. 2015;33(3):294---301

www.rpped.com.br

REVISTA PAULISTADE PEDIATRIA

ORIGINAL ARTICLE

Effect ofbreastfeeding on obesity ofschoolchildren:

influence ofmaternal education

Katia Jakovljevic Pudla, David Alejandro Gonzalz-Chica,Francisco de Assis Guedes de Vasconcelos

Universidade Federal de Santa Catarina (UFSC), Florianpolis, SC, Brazil

Received 30 October 2014; accepted 23 January 2015

Available online 29 June 2015

KEYWORDSBreastfeeding;Obesity;Schoolchildren

Abstract

Objective: To evaluate the association between duration of breastfeeding (BF) and obesity in

schoolchildren ofFlorianpolis (SC), and the role ofpossible effect modifiers.

Methods: Cross-sectional study with a random sample of 2826 schoolchildren (7---14 years).

Weight and height were measured according to standardized procedures. Data concerning BF

and sociodemographic variables were obtained from a questionnaire sent to parents/guardians.

Childrens nutritional status was evaluated by BMI-for-age z-score for gender (WHO reference

curves). Adjusted analyses were performed through logistic regression, considering a possible

interaction among variables.

Results: Prevalence of obesity was 8.6% (95% CI: 7.6---9.7%) and 55.7% (95% CI: 53.8---57.6%)

received breastmilk for 6 months. BF was not associated with obesity, even in the adjusted

analysis. Stratified analysis according to maternal schooling showed that, in children aged 7---10

years and children whose mothers had 0---8 years ofschooling, the chance ofobesity was lower

among those breastfeed for >1 month, especially among those who received breastmilk for 1---5

months (OR=0.22; 95% CI 0.08---0.62). Among children ofwomen with higher schooling (>8 years),

the chance ofobesity was 44% lower in those who were breastfed for >12 months (p-value for

interaction

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Effect ofbreastfeeding on obesity ofschoolchildren 295

PALAVRAS-CHAVEAleitamento materno;Obesidade;Escolares

Efeito do aleitamento materno sobre a obesidade em escolares: influncia da

escolaridade da me

Resumo

Objetivo: Avaliar a associaco entre a duraco do aleitamento materno (AM) e a obesidade em

escolares de Florianpolis (SC), assim como o papel de possveis modificadores de efeito.Mtodos: Estudo transversal com amostra probabilstica de 2.826 escolares de 7---14 anos. Foram

aferidos o peso e a altura dos escolares, de acordo com procedimentos padronizados. Dados

referentes ao AM e variveis sociodemogrficas foram obtidos por questionrio enviado aos

pais/responsveis. O estado nutricional foi avaliado pelo escore-Z IMC/idade (curvas da OMS),

de acordo com o sexo. Anlises ajustadas foram feitas com regresso logstica e foi considerada

a possvel interaco de variveis.

Resultados: A obesidade afetou 8,6% dos escolares (IC95%: 7,6---9,7%) e o AM por seis meses

foi encontrado em 55,7% (IC95%: 53,8%-57,6%). O AM no esteve associado obesidade, mesmo

nas anlises ajustadas. As anlises estratificadas por escolaridade materna mostraram que, nas

criancas de 7-10 anos e filhos de mulheres com at oito anos de estudo, a obesidade foi menor

nos que receberam AM por qualquer perodo >1 ms, em especial entre aqueles que receberam

AM por 1-5 meses (RO=0,22; IC95%: 0,08---0,62). Nos filhos de mulheres com maior escolaridade

(>8 anos), a chance de obesidade foi 44% menor nos que haviam recebido leite materno por >12

meses (p de interaco

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296 Pudla KJ et al.

(WHO) reference curves,15 based on the recommendationsof Lohman, Roche and Martorell (1988).16 Body weight wasmeasured using an electronic Marte scale with 180kg capac-ity and accuracy of100 g, and height was measured using anAlturexata stadiometer, with accuracy of one millimeter.Data were collected between March and December 2007.

Data related to BF and other information used forthe control variables were obtained through a ques-

tionnaire sent to students parents/guardians. Birth andchildhood data of the schoolchildren (birth weight, ges-tational age and duration of breastfeeding), demographicdata (maternal schooling and age, total monthly income,number of household members) and anthropometric dataof the schoolchildrens mothers (self-reported weight andheight) were collected. The covariate sexual matura-tion was collected only in students aged 11---14 years,through a spreadsheet containing the figures correspond-ing to the sexual maturation stages proposed by Tanner17 indrawings.

BF data were obtained based on the following questionto the parents or guardians, How long was the studentbreastfed? This question was divided into breastfeedingtime categories, which were then grouped for data analysis.

The data were processed electronically in the softwareEpiData 3.0 and all data were verified and received auto-matic checks for consistency and amplitude.

The schoolchildrens nutritional status (outcome vari-able) was categorized as without obesity (z-score +2) orobese (>z-score +2), based on body mass index (BMI) curvesfor age and gender, according to the WHO reference curves(2007).18 For comparative analysis, nutritional status wasalso classified according to the recommendation ofthe Inter-national Obesity Task Force (IOTF), according to Cole et al.19

The intention of this comparison was to verify whether theassociation results were similar, as most of the studies on

the subject used a different classification than that used bythe WHO (2007).18

The BF (exposure variable) was analyzed in two differ-ent ways: first, it was categorized dichotomously as neverreceived breastmilk/received for 8 years), maternal nutritional status(underweight/normal weight, BMI

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Table 1 Crude Odds Ratio (OR) for obesity according to characteristics of the students aged 7---14 years, their mothers and

families. Florianpolis, SC, 2007.

Variables 7---10 years (n=1232) 11---14 years (n=1594)

n (%) OR p n (%) OR p

Students gender 8 years 871 (73.5) 0.95 (0.60---1.50) 1016 (65.7) 0.76 (0.44---1.31)

Maternal nutritional

status

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298 Pudla KJ et al.

Table 2 Prevalence (%) of obesity, crude and adjusted Odds Ratio according to breastfeeding and breastfeeding duration

categories, stratified by age. Florianpolis, SC, 2007.

Variable % Crude OR p-value Adjusted OR p-value

7---10 years

Maternal breastfeeding 0.308 0.320

- Never/

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5.0

4.0

3.0

2.0

1.0

0.0

5.0

4.0

3.0

2.0

1.0

0.0

p=.21

Never /

12

months

0.65 0.560.520.22

Maternal schooling 0-8 years Maternal schooling >8 years

Never /12months

Maternal schooling 0-8 years Maternal schooling >8 years

Schoolchildren aged 11 to 14 years

p=.96

0.620.76

1.67

1.08 1.02

0.72AdjustedOd

dsratio**

p=.02

3.47

4.06

Schoolchildren aged 7 to 10 years

p=.003

Adjus

tedOddsratio*

Figure 2 Association between maternal breastfeeding and

obesity according to breastfeeding duration categories, strat-

ified by age and maternal schooling. Florianpolis, SC, 2007.

* Adjusted for gender, maternal nutritional status and birth

weight. ** Adjusted for gender, maternal nutritional status,maternal education, gestational age at birth and sexual mat-

uration.

questionnaires are reliable tools and applicable for theself-reporting of experiences related to breastfeeding,regardless of time of data questioning, and can, therefore,be used in this type of study.3,25

BF in this study was not associated with obesity in thecrude and adjusted analyses, and this effect was also main-tained when using the classification by Cole et al.19 However,when verifying the interaction of the maternal schoolingvariable in this association, it was observed that, among

schoolchildren aged 7---10 years, the odds of obesity inchildren of women with less schooling was lower in thosebreastfed for a month or more. In children ofwomen higherschooling, the protective effect was evident only in thosewho received breastmilk for more than 12 months, whereasintermediate periods ofBF were associated with higher oddsofobesity.

Several systematic reviews have been carried outregarding this association; among them, Arenz et al.26

showed a small, but consistent effect ofBF against the riskof obesity in later childhood (OR=0.78; 95% CI: 0.71---0.85).The WHO3 also performed a systematic review in which, inaddition to this study,25 three other systematic reviews and

two more studies were analyzed. The result of the reviewindicates a small, but protective effect of BF regarding theprevalence ofobesity.

Nevertheless, the literature shows controversial resultsfor this association: some studies found null results,7,8

while others demonstrate that the type and duration ofBF protect against obesity.4,5 Among the reasons for thediscordant results found in the literature is the hetero-

geneity of the studies, with differences in the age of theindividuals, the research site, and the criteria for BF andobesity assessment.6 Most of the studies were carried outin North America and Western Europe,3 with few stud-ies being performed in lower-income countries, includingBrazil---in fact, there are few studies comparing resultsfrom high-income countries with results from Brazil. Theresearch performed by Brion et al.12 with cohorts fromthe UK and Brazil (Pelotas city --- RS), with samples aged9 and 11 years, respectively, found an inverse associationbetween duration ofBF and BMI only in the European cohort( =0.16; 95% CI: 0.22, 0.09). In Pelotas, however, inaddition to not finding an association, there was a trendof BF association with higher BMI ( =0.14; 95% CI: 0.07;0.36).

In a review ofstudies published from 2005 to 2012, Lefeb-vre and John10 concluded that this association is still unclear,especially due to the fact that several confounding factorsmay influence this association.

In the present study, we tried to adjust the analysesconsidering the main control variables in the associationbetween BF and obesity, among which are socioeconomicand demographic factors and maternal variables.3 Neverthe-less, the associations became evident only when maternalschooling was introduced in the analyses as an effect modi-fier. The literature shows a lower chance, as well as similarchance of obesity, according to the BF duration.4,7 There

have been studies that even indicate a trend of lowerchance of obesity as the duration of BF increases, witha dose---response effect in this association,4 a fact thatwas not observed in this investigation. Moreover, the BFdose---response effect on obesity is more evident for exclu-sive breastfeeding. The literature indicates that exclusiveBF, when maintained for a longer period of time, protectschildren and adolescents from excess weight, as the compo-sition of breast milk contributes to adequate growth.5,27

However, the exclusive BF variable was not measured inthis study, and it was not possible to discuss the differ-ences between the type of breastfeeding and its influenceon excess weight.

The higher odds ofobesity among children ofwomen withmore schooling who stopped breastfeeding before reach-ing 12 months could be related to the introduction ofother types of milk and/or foods with high energy den-sity. This hypothesis is reasonable, considering the increasein the consumption of processed foods by the Brazilianpopulation,28 which could be influencing childrens dietsafter weaning. However, this information was not collectedin this study.

We do not know the reasons for the lack of associa-tion between BF and obesity in schoolchildren aged 11---14years, because even after adjustment for sexual maturation,no statistically significant associations were demonstrated.New studies with longitudinal design could help in this issue.

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300 Pudla KJ et al.

Furthermore, there is the time limitation of the study,in which the prevalence and associations may have beendifferent due to a cohort effect. In Brazil, the BF incentivepolicies started in the 1990s, and there was an increase inthe median breastfeeding time between the period of1993and 2004.29,30 Thus, this difference in the schoolchildrensbirth period would be a limitation in the analysis and couldalso explain the effect modification between the two age

groups.In conclusion, we emphasize that there is satisfactory

evidence ofthe several BF benefits, which should be encour-aged for the period recommended by the WHO.3 We alsoemphasize that studies aiming to investigate the effects ofBF on the nutritional status ofchildren and adolescents needto consider in their methodology not only the control ofcon-founding factors, but also the possible effect modification bysocioeconomic variables. Further studies should be carriedout to assess this association, especially in lower-incomecountries, in addition to the implementation ofprospectivestudies that will allow making a more precise inference,analyzing the association between obesity and exclusivebreastfeeding, with the age ofintroduction ofother foods.

Funding

Conselho Nacional de Desenvolvimento Cientfico eTecnolgico (CNPq) --- Process n. 402322/2005-3-EdictMCT/CNPq/MS-SCTIE-DECIT/SAS-DAB 51/2005.

Conflicts ofinterest

The authors declare no conflicts ofinterest.

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