CHILDHOOD OBESITY

August 2015 j Volume 11, Number 4

Mary Ann Liebert, Inc.
DOI: 10.1089/chi.2015.0026

Association between Breastfeeding

and Childhood Obesity:
Analysis of a Linked Longitudinal Study
of Rural Appalachian Fifth-Grade Children
Amna Umer, BDS, MPH, PhD(c),1 Candice Hamilton, MPH,2 Cris M. Britton,2
Martha D. Mullett, MD,2 Collin John, MD, MPH,2 William Neal, MD,2 and Christa L. Lilly, PhD 3

Abstract
Introduction: Although breastfeeding is associated with improving numerous health outcomes for the child, its role in
reducing childhood obesity is contested. Despite this controversy, both the CDC and the US Department of Health and Human
Services promote breastfeeding as one of the strategies for reducing childhood obesity. Rural Appalachia has one of the
highest rates of childhood obesity and low rates of breastfeeding, compared to rest of the nation. The aim of this study was to
examine the association between breastfeeding and childhood obesity at 11 years in the rural Appalachian state of West
Virginia (WV).
Methods: The study used linked data from two cross-sectional data sets to examine this relationship longitudinally in fifth-grade
WV children. The main outcome variable was BMI adjusted percent (BMI%) and the main exposure was defined as occurrence of
breastfeeding. Mean BMI% of children who were not breastfed was significantly higher, compared to children who were breastfed.
Results: The result of the multiple regression analysis showed that breastfeeding significantly predicted BMI% of children after
controlling for maternal education, health insurance, family history of hypercholesterolemia and diabetes, childs asthma status, and
birth weight of the infant.
Conclusions: Our results are consistent with other studies that have shown a significant, but small, inverse association between
breastfeeding and childhood obesity. Findings from this study suggest the need to improve breastfeeding rates in the rural Appa-
lachian state of WV as one of the potential strategies to prevent obesity during childhood and adolescence.

Introduction risks associated with it, marks this as one of the most im-
portant public health concerns and challenges.6
n the United States, approximately one third of children Whereas several strategies have been recommended to

I and adolescents ages 219 are overweight or obese.1

Obesity prevalence is higher in rural regions of the
United States, compared to urban areas.2 West Virginia
(WV), a predominantly rural Appalachian state, has one of
the highest rates of obesity in the nation.3,4 Childhood
obesity has been linked to several health conditions, such as
high blood pressure and cholesterol, type 2 diabetes (T2D),
psychosocial problems, and an increased likelihood of
tracking from childhood into adulthood.5 The alarmingly
high rates of childhood obesity, and the numerous health
reduce obesity, the CDC and the US Department of Health
and Human Services promote breastfeeding as an early
strategy for reducing later childhood obesity.7 Recent re-
search suggests that breastfeeding significantly predicts
positive health outcomes for both the mother and the child,
including reducing childhood obesity.810 Two recent
meta-analyses found a 15% decrease (adjusted odds ratio
[AOR] = 0.85; 95% confidence interval [CI], 0.740.99)
and a 22% decrease (AOR = 0.78; 95% CI, 0.740.81) in
the odds of childhood overweight and obesity comparing

1
Department of Epidemiology, School of Public Health, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, WV.
2
Department of Pediatrics, School of Medicine, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, WV.
3
Department of Biostatistics, School of Public Health, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, WV.

1
2 UMER ET AL.
breastfed with nonbreastfed infants.11,12 Some individual
studies have demonstrated an even higher relative risk
reduction (ranging from 25% to 35%) in childhood obe-
sity comparing children who were breastfed versus not
breastfed.13,14 However, the association between breast-
feeding and obesity is inconsistent across studies.1117
Some studies have found this association only with over-
weight (BMI between 85th and 94th percentile) children,
but not with obese (95th percentile) children,15 whereas
other studies have shown no association between breast-
feeding and childhood obesity.16,17
Regardless of the link between childhood obesity and
breastfeeding, current guidelines by the American Acad-
emy of Pediatrics suggest 6 months of exclusive breast-
feeding to achieve the best possible health outcomes for the
child.18 However, data from the 2011 National Immuniza-
tion Survey suggest that only 18.8% of mothers in the
United States and 12.2% of mothers in WV exclusively
breastfeed during the first 6 months. The percentage of
mothers who initiate breastfeeding postpartum is also much
lower in WV (59.3%), compared to the national average
of 79.2%.19,20 Lower breastfeeding rates, along with higher
obesity rates, are similarly found throughout rural Appa-
lachia.21
Given lower breastfeeding rates and higher obesity
rates, as compared to the national average, it is important
to examine the association between childhood obesity and
breastfeeding in the rural Appalachian state of WV.
Specifically, the aim of this study was to examine dif-
ferences in BMI adjusted percent (BMI%) of fifth-grade
WV children who were breastfed versus not breastfed
during infancy. This study hypothesized, consistent with
research in other regions of the United States, that non-
breastfed children will have higher BMI% compared to
their peers.
Methods
The study used data from two projects, the WV Birth
Score Project and the Coronary Artery Risk Detection in
Appalachian Communities (CARDIAC) Project. The WV
Birth Score Project is an infant risk-screening instrument
that was initiated in 1985. Trained healthcare professionals
collect data on every newborn born in the state of WV
within 2448 hours or preceding discharge, with the goal
of identifying infants who are at a high risk of poor health
outcomes or mortality in the first year of life in order to
provide referrals to primary care management.22 In this
study, data collected on children participating in the Birth
Score Project born between January 1999 and October
2002 were merged with data collected by the CARDIAC
Project in years 20112012. The CARDIAC Project col-
lects data on fifth-grade children in schools across all 55
counties in WV with the goal of identifying children at risk
of cardiovascular disease. Further details of the data col-
lection procedure are described elsewhere.23 The West
Virginia University Institutional Review Board approved
the study and the merged analysis. The current study linked
the two data sets based on the childs identification number
and included only those observations where data were
available from both projects.
Measures
Dependent variable. The main outcome variable was de-
fined as the BMI% of the children above the ideal BMI for
their age and gender. Trained area coordinators, nurses, and
health science students measured the childrens height and
weight using the SECA Road Rod stadiometer (7800 /200 cm)
and the SECA 840 Personal Digital Scale, respectively (Seca
Corp, Hanover, MD).24 CDC EpiInfo software (v. 3.5) was
used to calculate BMI, height, and weight percentiles ad-
justed for childrens age and gender, and BMI z-scores were
based on these percentiles. From US CDC 2000 growth
charts,25 childrens sex-/age-specific median was calculated
and subsequently the percentage difference from median
BMI (BMI%24) was calculated using 100*log BMI/median
BMI. BMI% has shown to be an effective measure of adi-
posity change in growing children.26
Independent variable. Exposure was defined as occur-
rence of breastfeeding. Information related to breastfeed-
ing was obtained using the CARDIAC questionnaire
retrospectively when the child was in fifth grade by
parental/caregiver recall. The question stated, Was your
child breastfed?, and answer options included yes,
no, and dont know.
Covariates
Sociodemographics. Sociodemographic variables in-
cluded maternal and childs age, race/ethnicity/sex of the
infant, maternal education, and health insurance status.
Maternal age at the time of infants birth was recoded as a
continuous variable. Given that WVs population is pre-
dominately white (94%), the race of the infant was self-
reported by the mother and was dichotomized as white
and other for this analysis.27 The sex of the child was
recorded at birth. The age of the child at fifth grade was
recoded as a continuous variable and was self-reported
by parents/caregivers. Maternal education has also been
shown to be a strong predictor of a childs weight and
also a predictor of a mothers breastfeeding practices.28
The maternal education at time of birth included the
number of years of education received and ranged from 1
to 17. Maternal health insurance at the time of birth was
categorized as a binary variable (Medicaid and non-
Medicaid). A recent study concluded that key demographic
characteristics, such as race and socioeconomic status
(SES), play an important role in the mothers decision and
duration to breastfeed her child.29
Family history of risk factors. Parental overweight is a
strong predictor of childhood obesity.30 The study did not
have data on parental weight but included family history of
CHILDHOOD OBESITY August 2015
diabetes and family history of hypercholesterolemia (HCS),
owing to the genetic predisposition of these variables and
their association with obesity.31,32
Other infant, maternal, and child characteristics. Also
included in the analysis were other potential confounders
that have been linked to childhood obesity (outcome only)
or both to breastfeeding and childhood obesity, including
infants birth weight in grams, maternal smoking status
(yes/no), and childs asthma status (yes/no).11,33 Whereas
several studies have suggested that obesity is a risk factor
of asthma,33 others have argued that sedentary lifestyle and
physical inactivity in asthmatic individuals could result in
increased weight gain.34 There is also decreased risk of
asthma in children who are breastfed versus formula fed.9
Literature suggests that intent to breastfeed is a strong
predictor of actual breastfeeding practices in the postpar-
tum period, and thus this variable was also examined.35
The variable was binary with the following response op-
tions: breastfeed and bottle or both. 30% children had family history of HCS, 53% had a family
Statistical Analysis
All statistical analysis was conducted in SAS software
(version 9.3; SAS Institute Inc., Cary, NC). An indepen-
dent sample t-test was used to initially determine if there
was a statistically significant difference in the unadjusted
mean BMI% of WV children who were breastfed during
infancy versus those not breastfed, and the magnitude of
this association was calculated using Cohens d effect size.
Multiple regression analysis was then used to assess
the adjusted relationships after controlling for covariates.
Only covariates significant in the Spearmans correlation
analysis were used in the multiple regression models. The
significant covariates included: infant birth weight in
grams; maternal education status as 117 years of educa-
tion; maternal insurance status (Medicaid and non-
Medicaid); family history of diabetes (yes/no); family
history of HCS (yes/no); child asthma status (yes/no); and
intent to breastfeed (breastfeed/both). Covariates that were
not significant and were excluded were: maternal age;
maternal smoking status; and childs age, race, and gender.
We also excluded the intent to breastfeed variable from the
full model because of multicollinearity between the intent
to breastfeed and actual breastfeeding variables (r = 0.64;
p < 0.0001).
A general linear model was used to test the primary
hypothesis in order to adjust for covariates. The regres-
sion F statistic was used to determine the overall signif-
icance of the regression model and a corresponding
p value of 0.05 was considered significant. The ability of
each independent variable to predict the outcome variable
was also assessed for significance at alpha 0.05 by ex-
amining the parameter estimates and their corresponding
t-test values. The squared multiple correlation coefficients,
R2 and adjusted R2, were interpreted as the effect size of
the regression model. The study also performed the re-
3
gression analysis with (full model) and without (covariate
model) the main predictor variable (i.e., breastfeeding).
The change in R2 was then calculated to determine the
unique amount of variance shared between breastfeeding
and BMI%.
Results
A total of 5929 subjects were available for analysis with
the merged data. Fifty-eight percent of newborns in the
Birth Score Project had data in the CARDIAC data set in
fifth grade. From the Birth Score Project data, 94% infants
were categorized as white, and the maternal age at time of
delivery was 25.8 years (standard deviation [SD], 5.7).
The average birth weight was 3239.9 g (SD, 535.6).
Approximately 48% of the women said they intended to
breastfeed at birth. Consistent with the Birth Score Project
demographics, from the CARDIAC data, 41% of women
subsequently said they breastfed their infant. Mean age of
children in fifth grade was 11.0 years (SD, 0.5). Nearly
history of diabetes, and 16% had asthma. Mean BMI% of
fifth graders was 18.7% (SD, 22.7).
Mean BMI% of WV children who were breastfed versus
those who were not breastfed was statistically significant
(t(5790) = 5.54; p < 0.0001; d = 0.15). Mean BMI% of chil-
dren who were not breastfed was 20.03% (95% CI, 19.24
20.82) and those who were breastfed were 16.68% (95%
CI, 15.8117.55), and the mean difference was 3.35%
(95% CI, 2.164.54; Fig. 1).
The result of the multiple regression analysis showed
that breastfeeding was significantly and inversely associ-
ated with BMI% of children with inclusion of covariates
in the model (F(8, 4844) = 38.88; p < 0.0001; adjusted
R2 = 0.0519). Covariates including maternal education,
insurance status, family history of HCS and diabetes,
childs asthma status, and birth weight of the infant were
Figure 1. The result of the independent samples t-test showed a
statistically significant difference in mean BMI adjusted percent of
WV children who were breastfed vs. not breastfed ( p < 0.0001),
using data from 1999 to 2002 from the Birth-Score project merged
with 20112012 data from the CARDIAC Project (N = 5929). X-
axis: mean BMI adjusted percent (BMI%). Y-axis: breastfeeding
(yes vs. no).
 Table 1. Results of the Multiple Regression Analysis for All the Variables in the Model to Predict BMI Adjusted
Percent (BMI%) of Fifth-Grade WV Children
Covariate model only Full model
Unstandardized Unstandardized
regression Standardized regression Standardized
coefficients regression coefficients regression
Variables and 95% CI coefficients t value Pr > jtj and 95% CI coefficients t value Pr > jtj
Intercept 10.34 (4.9915.70) 0 3.79 0.0002 9.09 (3.6914.48) 0 3.30 0.0001
Maternal education - 0.56 (-0.88 to -0.24) - 0.05 - 3.40 0.0007 - 0.43 (-0.75 to -0.10) - 0.04 - 2.55 0.0108
Health insurance - 3.76 (-5.15 to -2.36) - 0.08 - 5.29 < 0.0001 - 3.49 (-4.84 to -2.03) - 0.08 - 4.87 < 0.0001

4
History of diabetes 5.25 (3.986.51) 0.12 8.14 < 0.0001 5.21 (3.946.48) 0.11 8.05 < 0.0001
History of hypercholesterolemia 3.73 (2.355.11) 0.08 5.29 < 0.0001 3.77 (2.395.16) 0.08 5.34 < 0.0001
Birth weight 0.004 (0.0030.005) 0.09 6.39 < 0.0001 0.004 (0.0030.005) 0.09 6.62 < 0.0001
Asthma status 5.57 (3.847.29) 0.09 6.33 < 0.0001 5.61 (3.887.34) 0.09 6.36 < 0.0001
Breastfeeding (yes vs. no) - 2.48 (-3.79 to -1.16) - 0.05 - 3.70 0.0002
Only covariates that were significant in the Spearmans correlation were used in the multiple regression analysis. Covariates included infant birth weight in grams, maternal
education status as 117 years of education, maternal health insurance status at time of delivery (non-Medicaid vs. Medicaid), family history of diabetes (yes vs. no), family history
of hypercholesterolemia (yes vs. no), and childs asthma status (yes vs. no). Covariates that were not significant and were excluded were maternal age, maternal smoking status,
childs age, race, and gender.
WV, West Virginia; CI, confidence interval.
CHILDHOOD OBESITY August 2015
statistically significant in predicting variance in BMI%
of the child (Table 1). The change in R2 when including
the breastfed variable was 0.24%, which demonstrates
that a small amount of unique variance is shared be-
tween breastfeeding and BMI% of the child after covariate
inclusion.
Discussion
The results indicated that the mean BMI% was signifi-
cantly lower among children (age 11 years) who were
breastfed, compared to children who were not breastfed, by
a significant difference of nearly 3.4%. Additionally, the
regression model showed that, compared to children who
were not breastfed at infancy, there was a 2.5% decrease in
the BMI% of children who were breastfed even after
controlling for covariates. However, the change in R2
showed that breastfeeding accounted for less than 0.25% of
unique variance in BMI% of children. Our results are
consistent with other studies that have shown a significant,
but small, inverse association between breastfeeding and
childhood obesity.30
Several covariates were not included in this study owing
to lack of bivariate association, despite previous research
suggesting the importance of inclusion. For example,
previous research has observed this association mostly
among non-Hispanic whites and not among other racial/
ethnic groups.36 However, this study did not find race/
ethnicity to be a significant factor in the bivariate analysis
and thus did not include this variable in the regression
model. This may be because WV has a predominately
white population (94%) consistent with Appalachian
characteristics.27 Moreover, our study did not find signifi-
cant bivariate correlations between the main outcome of
interest (BMI%) and maternal smoking status, maternal
age, and childs age and sex and therefore did not include
these covariates in the regression model. Weng and col-
leagues also found no association between maternal age, as
well as the childs race/ethnicity and childhood obesity.11
However, two systematic reviews found significant asso-
ciations between maternal smoking during pregnancy and
obesity in children.11,30 This null finding within our data
was surprising, given that WV has one of the highest rates
of smoking during pregnancy.37
Significant covariates included in the study also bear
some interpretation. The results suggest that with in-
creasing years of maternal education at time of the childs
birth, there was a decrease in the childs BMI%. Previous
research has noted that maternal education is related to
breastfeeding initiation and continuation, in addition to the
childs weight.38 The study used maternal health insur-
ance status for maternal SES and found that children
whose mother had Medicaid versus non-Medicaid health
insurance at the time of birth had significantly higher
BMI%. Data show that maternal SES plays an important
role in the mothers decision and duration to breastfeed
her child.29 In addition, high infant birth weight has also
5
shown to be risk factors for childhood overweight.11
Our study also showed that there was a significant in-
crease in the childs BMI% with increasing birth weight.
Although family history of overweight and obesity has a
strong association with obesity in children, this infor-
mation was not available in either of the two data sets.
However, controlling for family history of HCS and di-
abetes showed that children who had a family history of
these illnesses had significantly higher BMI%. Asthma is
also another potential confounder related to both expo-
sure and outcome and was thus controlled for in this
analysis.9,33,34 The study found that children who had
asthma had a significant increase in BMI%, compared to
children without asthma.35
Our results are in concordance with other studies that
have indicated a significant association between breast-
feeding and the reduced risk of weight gain in children
and adolescents after controlling for potential confound-
ing variables.13,30,36 However, some of the limitations of
the study include lack of information on important con-
founders, such as parental overweight or obesity status,
childs physical activity, and dietary behaviors.30 In-
formation on actual breastfeeding was obtained retro-
spectively and thus is subject to recall bias and also to
social desirability bias, given that women who believed
that they should have breastfed were probably different
from those that did not think breastfeeding was important.
The measure also did not inquire about the duration or
exclusivity of breastfeeding, or timing of solid food in-
troduction, which may be important components when
examining this association.12,39,40 In addition, the results
from the regression analysis showed that although the
predictors accounted for nearly 5% of the variance in
BMI%, breastfeeding uniquely accounted for less than 1%
of the variance. However, the small effect size of breast-
feeding and childhood obesity is consistent with other
studies.30
Some of the strengths of the study included the ability to
examine this association longitudinally using linked data
from two cross-sectional studies. Moreover, the main
outcome variable (BMI%) was calculated by measuring
height and weight by trained healthcare professionals. The
study used BMI% to overcome the ceiling effects in the
tails of the normal distribution observed in other adiposity
measures, owing to the fact that obesity in children is ob-
served mainly by an increase of BMI distribution in the
upper percentiles.24,26 This is particularly important given
that breastfeeding may shift only the upper tail of the BMI
distribution to the left and not the whole distribution.41 To
our knowledge, no study has examined the association
between breastfeeding and childhood obesity taking into
account the percentage difference between BMI and me-
dian BMI of children.
The numerous benefits of breastfeeding for both the
mother and the child have been well documented in de-
veloped countries as well as in the United States.8,42 The
Appalachia region of the United States has one of the
6 UMER ET AL.
highest rates of childhood obesity and the lowest breast-
feeding rates in the nation. For example, the CDC Survey
of Maternity Practices in Infant Nutrition and Care
(mPINC) provide data on the extent to which evidence-
based hospital practices and policies help mothers achieve
their breastfeeding goals. WV had one of the lowest
mPINC scores in the nation (higher score shows higher
prevalence of maternity care practices that are supportive
of breastfeeding).43 Although the effect size of this study
was small, considering the magnitude of the childhood
obesity crisis, this finding suggests the need to improve
breastfeeding rates in rural Appalachia as one of the
strategies to prevent obesity during childhood and ado-
lescence.
Conclusions
In conclusion, this study showed that breastfeeding is
protective against childhood obesity among fifth-grade
school children in the state of WV. Our study adds to the
argument of encouraging breastfeeding as one of the po-
tential preventative measures in reducing childhood obe-
sity prevalence.
Acknowledgments
The West Virginia Birth Score Program is funded under
an agreement with the West Virginia Department of Health
and Human Resources, Bureau for Public Health, Office of
Maternal, Child and Family Health. The CARDIAC pro-
ject is funded by the West Virginia Bureau of Public
Health. The authors thank the children and families who
have participated in the CARDIAC Project and the Birth
Score Project
Author Disclosure Statement
No competing financial interests exist.
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Address correspondence to:
Amna Umer, BDS, MPH, PhD(c)
Department of Epidemiology
School of Public Health
Robert C. Byrd Health Sciences Center
West Virginia University
Morgantown, WV 26506
E-mail: amumer@mix.wvu.edu