Sandra Hassink, MD
Dupont Children’s Hospital
Thomas Jefferson University
Wilmington, DE
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PRE-TEST (detailed explanations at the bottom):
Q1. Risk factors for developing obesity include:
A. Exposure to maternal diabetes in utero
B. Obesity in one or both parents
C. Membership in Hispanic, African American or Native American ethnic group.
D. Low socio-economic status
E. Maternal smoking
F. All of the above
Q2. Promotion of breastfeeding is a viable strategy for preventing obesity (True or False)
Q3. True or False Breast feeding can reduce the risk of obesity.
Q4. Factors, which may interfere with the development of normal feeding/eating patterns in infancy, EXCEPT:
A. Responding to crying or distress with feeding.
B. Maternal need to nurture with feeding
C. Maternal depression
D. Missed satiety cues
E. Maternal age
F. All interfere
OBJECTIVES:
1. Learn how to recognize risk factors for developing obesity considering the intrauterine environment and family history.
2. Understand how to assess and help the family assess the behavioral and environmental factors, which may increase the chances of developing obesity.
3. Understand the impact of breastfeeding in preventing obesity.
4. Be able to develop and help the family implement a plan to reduce risk of obesity in an at risk newborn.
FACILITATOR PREPARATION:
There is recognition of the importance of the intrauterine environment as a critical period for determining later risk of obesity and the obesity related co morbidities of diabetes and cardiovascular disease. Barker noted an increased incidence of obesity, hypertension, diabetes and cardiovascular disease in adults who experienced intrauterine malnutrition as manifested by low birth weight. In addition, babies that are small for gestational age and born into an overabundant nutritional environment and experience a relative calorie surplus in the face of intrauterine programming for deprivation followed by early life overfeeding are most at risk for later obesity and related comorbidities. This theory (from Barker, Singhal, and Lucas) fits with an older hypothesis from Knittle and Hirsch suggesting that fat cells accumulate and never diminish in number. For further discussion, see -
1. Whitaker, RC, Dietz WH. Role of the prenatal environment in the development of obesity. J Pediatr. 1998May: 132(50:768-76. and
2. Gillman MW, Rifas-Shiman SL, Camargo CA et al. Risk of overweight among adolescent who were breastfed as infants JAMA, 2001 285 2461-2467.
3. Barker DJ. The developmental origins of chronic adult disease. Acta Paediatr Suppl. 2004 Dec;93(446):26-33
4. Singhal A, Lucas A. Early origins of cardiovascular disease: is there a unifying hypothesis? Lancet. 2004 May 15;363(9421):1642-5.
INTRODUCTION
The onset of obesity in childhood is a result of genetic predisposition in the setting of a permissive bio/behavioral environment. Intrauterine environmental conditions may also increase obesity risk. Understanding the risk for obesity and the environmental factors, which can be altered to reduce risk, is crucial and begins at birth.
Identifiable in-utero risk factors increase obesity risk. These include, children born from a pregnancy complicated by gestational diabetes (1) or born to a mother with diabetes (2,3,4,5,), maternal smoking (6) or a newborn who is small for gestational age (7,8). In addition children from families with a history of the metabolic syndrome (diabetes, hypertension, obesity and hyperlipidemia) may also be considered at increased risk for obesity. These risk factors highlight the significant impact of genetics and the emergence of the intrauterine environment as an important determinant of later health. However, one cannot explain the rising global incidence of obesity on congenital factors. Changes in post natal social environment are of great importance.
The family stands at the interface between the child and his/her response to the environment. Helping families recognize patterns of feeding and eating, activity and inactivity, which place their child at risk and helping families change these behaviors, is the primary focus of an obesity intervention in infancy. Factors such as cued feeding, response to infant distress, conflicting sources of information about proper feeding can all result in nutritional patterns which will trigger genetic predisposition to excess weight gain.
While the difference in mean birth weight between the higher and lower socioeconomic groups may seem small (about 150 grams), this difference is associated with a substantial increase in the number of low birth weight infants.
Figure 1.
TEACHING CAPTION: The darkened area represents the resultant increase in numbers of low birth weight infants. From Scholl TO. Nutrition in teen pregnancy. (1993) in Karp RJ (ed) Malnourished Children in the United States: Caught in the Cycle of poverty. Springer Publidhing Co of NY. (with permission).
A Case History:
You first meet Mr. and Mrs. S and their new baby girl in the hospital. You notice that both parents are significantly overweight. You obtain a family history and note that 3 of the four grandparents had hypertension, diabetes or cardiovascular disease and several of Mrs. S‘s sisters had gestational diabetes. Sharon S weighed 4,080 gms (9 lb. 10oz) at birth and Mrs. S notes that she had “trouble with her blood sugar” during the last trimester of her pregnancy.
Q1 What issues would you choose to discuss
A1 In your discussion with Mr. and Mrs. S you point out that Sharon has a family history for obesity that places her “at risk” for obesity and related complications. You stress the importance of developing a long-term plan to help prevent obesity. This begins in infancy. It is family based and stresses sound nutrition with emphasis on activity and careful monitoring of growth. You begin discussing the importance of breastfeeding (9).
The Case continues:
Mrs. S tells you that she wants to breastfeed but is unsure if she can because both of her sisters had difficulty doing so.
Q2. What is your response? [Ask this question to the attendees]
A2. You restate Mrs. S’s concern and then agree with Mrs. S about the importance of breastfeeding in general and in her infant in particular. Obese women may have more difficulty initiating and sustaining breastfeeding than women may with normal BMI before pregnancy (10). You encourage Mrs. S to breast-feed and while discussing the benefits arrange for her to meet with a lactation consultant before leaving the hospital. Note the importance of team delivered care!
Q3. What risks might be of concern if this had been a low birth weight infant?
A3. There have been associations drawn between prenatal undernutrition and risk of cardiovascular disease and diabetes (11). This is the “Barker” Hypothesis: Adaptation of the fetus to a limited supply of nutrients is likely to alter its physiology and metabolism setting the stage for diseases of abundance when the individual experiences abundance later in life. Singhal and Lucas provide an alternative explanation. They suggest that the neonatal response to prenatal deprivation is the origin for the later findings of hypertension, diabetes, and coronary heart disease associated with the metabolic syndrome (12).
The case continues:
Mrs. S returns to your office in 2 weeks. Breast-feeding is going fairly well but she is very concerned that Sharon “is not getting enough to eat”.
Q4 what do you do now? [Again use this as a chance to engage.]
A4 You weigh and measure Sharon, plot weight, height and weight for length and reassure Mrs. S that she has gained the appropriate amount of weight (about 25 grams a day) and show Mrs. S the baby’s growth chart. Note that the commonly recommended “30 grams per day” is about the growth velocity (birth to 3 months) for infants born and remaining at the 95th %ile for weight of a given age and gender. A 25 grams per day weight gain would hold the percentile at 3 months of age to about the 75th percentile. You ask if Sharon seems content after feeding and help Mrs. S to look for satiety cues such as pulling off the breast, slowing down, looking around that can help Mrs. S identify that Sharon has had enough to eat which would indicate satiety. Use this opportunity to discuss appropriate weight gain in early infancy and weigh for length charts.
FIGURE 2. A Weight for Age Curve
TEACHING CAPTION: As the figure shows, weight gain of 25gms/day results in a healthy baby who, by 5 months of age, is almost a kilo lighter than an infant who gains 30gms/day.
The case continues:
Mrs. S also notes that it is very distressing for her to hear her baby cry and she often feeds Sharon right away when she seems distressed.
Q5. Again, what do you do now?
A5. You go over causes of crying such as need to be changes, burped, comforting as well as hunger and encourage Mrs. S. think of this “list’ when she is responding to her baby’s cry.
The case concludes:
By the 2 month visit, baby S is gaining weight appropriately, and you begin to help Mrs. S assess the household for infant safety as a prelude to having an active infant in the home. You point out that TV is not appropriate for an infant and suggest activities such as reading, talking to the baby and taking the baby for a walk as alternatives.
You show Mrs. S the growth chart and congratulate her on her baby’s normal growth.
Q6. Does parenting style affect likelihood of obesity?
A6 Yes, Teaching effective parenting is essential in obesity prevention.
A remarkable study by Rhee and colleagues shows that an "Authoritative" parenting style is most effective in preventing obesity. Those of us who are parents will recognize that this is as a bit idealized, but Authoritative parents do their best to set expectations and put boundaries on behaviors. They are, at the same time responsive to their children's needs. That is, the child is give opportunities to make choices so long as he or she meets parental expectations and stays within boundaries that are set with the needs of the child in mind.
The worst outcome is with the locus of control remaining with the parent without parental sensitivity. This is the "Authoritarian" parent. Parents who respond to children's needs without establishing expectations are called "Permissive," while not establishing limits and expectations as well as not being sensitive is called (and is) "Neglectful" parenting.
Rhee KE, Lumeng JC, Appugliese DP, Kaciroti N, Bradley RH. Parenting styles and overweight status in first grade. Pediatrics. 2006 Jun;117(6):2047-54.
SUMMARY
What you will do in infants at highest risk for developing obesity is to encourage optimal feeding and provide behavioral support. You will help the family from falling into the pitfalls of overfeeding to alleviate supposed hunger or not breast-feeding for lack of support. You have been careful, however, not to restrict the intake of the infant you are setting the stage for the parents as the providers of optimum nutrition and activity for their child. Initially, breast feed 15 to 20 minutes on each breast every 2 to 3 hours. Bottle fed infants should be offered 2 to 3 ounces of iron fortified formulae at that same interval.
REFERENCES
1. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH Predicting obesity in young adulthood from childhood and parental obesity N Engl J Med 1997Sept 25; 337(13):869-873.
2. Dabelea D, Hanson RL, Lindsey RL, Petitt DJ, Imperator G, Gabir MM, Roumain J, Bennett PH, Knowler WC. “Intrauterine Exposure to Diabetes Convey risks for Type 2 diabetes and obesity” Diabetes 2000 Vol. 49 P2208-2211.
3. Pettitt DJ, Baird HR, Aleck KA, Bennett PH, Knowler WC. Excessive obesity in offspring of Pima Indian women with diabetes during pregnancy N Engl J Med 1983 Feb 3;308(5) 242.245
4. Silverman BL, Metzger BE, Cho NH, Loeb CA “Impaired glucose tolerance in adolescent offspring of diabetic mothers.
Relationship to fetal hyperinsulinism. Diabetes Care 1995May 18(5) 611-617.
5. Phipps K Barker DJP, Hales CN, Fall CHD, Osmond C, Clark PMS. Fetal growth and impaired glucose tolerance in men and women. Diabetologia 1993; 36; 225-228.
6. von Kries R, Toschke AM, Koletzko B, Slikker W Jr. Maternal smoking during pregnancy and childhood obesity. Am J Epidemiol 2002 Nov 15;156(100:954-61.
7.Veening MA, Van Weissenbruch MM, Delemarre-Van De Wall HA. Glucose tolerance, insulin sensitivity, and insulin secretion in children Born small for gestational age. J Clin Endocrinol Metab. 2002 Oct: 87910); 4657-61.
8.Whitaker RC, Dietz WH Role of the prenatal environment in the development of obesity J Pediatr 1998 May 132(5) 768-776.
9. Corrected reference: Gillman MW, Rifas-Shiman SL, Camargo CA Jr. Berkey CS, Frazier AL, Rockett HR, Field AE, Colditz GA. Risk of overweight among adolescents who were breasted as infants. JAMA 2001 May 16;285(19) 2461-2467.
10. Li R, Jewell S, Grummer-Strawn L. Maternal obesity and breast-feeding practices Am J Clin Nutr 2003 Apr: 77(4) 931-6.
11. Barker DJ. The developmental origins of chronic adult disease. Acta Paediatr Suppl. 2004 Dec;93(446):26-33
12. Singhal A, Lucas A. Early origins of cardiovascular disease: is there a unifying hypothesis? Lancet. 2004 May 15;363(9421):1642-5.
ANNOTATED ANSWERS
A1. The answer is False. All of these factors have been associated with later obesity. One cannot, however, necessarily ascribe a cause and effect I model. For example, endemic chronic poverty is likely to affect prevalence of obesity in ethic minorities in the United States. It is likely that both covariance and interaction occur.
A2. and A3. The answer for both is True. This module emphasizes the importance of breast-feeding without early supplementation as one part of obesity prevention in "at-risk" infants.
A4. The answer is E. Age will not affect recognition of signals.
