Abstract
As with many medical conditions, African Americans and subsegments of minority populations are disproportionately affected. The obesity rate is 33% among reproductive-aged Hispanic women and 41% among African American women. 2
I would like to start with a case study, representing a patient I often see while on call on labor and delivery. The patient is a 25-year-old Hispanic prima gravida woman presenting in labor at 39 weeks with ruptured membranes and a vaginal examination of long and closed. Her history was significant for gestational diabetes, controlled by diet, and obesity. She was admitted, underwent a failed 32-hour induction, developed preeclampsia, and subsequently delivered an 8.5-pound infant via cesarean section. She tried to breastfeed the first day but gave up. This patient illustrates an all-too-common scenario with the increasing rates of obesity. It is critical that we remind ourselves of the health implications obesity can have, not just on the mother but on the newborn as well. And, as we are now learning, the offspring of the newborn. The Healthy People 2020 Action Model to Achieve Healthy People 2020 overreaching goals highlight the importance of taking into consideration the social determinants of health and how they impact health throughout the lifespan, not just one point in time. 3
In addressing health disparities, we need to realize the changing demographics in the United States. According to the U.S. Census Bureau, minority babies are now the majority in the United States. Population estimate demonstrate that 50.4% of children younger than 1 year old last year were Hispanic, black, Asian American, or another minority group. 4 Overall, the highest number of unintended pregnancies occurred among black women, then Hispanic, then whites. Black women living at ≤100% of the poverty level had the highest unintended pregnancy rate of 160 unintended pregnancies per 1,000 women, whereas Hispanics at this poverty level had 130 per 1,000 unintended pregnancies compared with 80 per 1,000 women among white women, illustrating that increasing poverty among minority women is associated with increased unintended pregnancies. 5 The age group with the highest unintended pregnancy rates are among 15 to 19 year olds, at 82%. 5 When looking at breastfeeding, recall that there is a higher discontinuation rate among young mothers and those of low socioeconomic status and lower education, the precise group that tends to be at highest risk for unintended pregnancies. 6
Education, according to the U.S. National Institutes of Health, highlights that, along with poverty, less schooling is linked to obesity and chronic disease. More educated people with higher incomes suffered fewer chronic diseases and live longer than less educated poor people. Twenty-four percent of boys and 22% of girls were obese in homes where the parents did not graduate from high school, and 11% of boys and 7% of girls were obese in homes where parents have a college degree. 7 One recommendation that we have overlooked in addressing the obesity crisis is the promotion of graduating from high school and completing college.
Overall, in the United States, two-thirds of Americans are overweight or obese. African Americans have the highest rates, with a predominant occurrence in the Southeast. Similar high rates occur among Hispanics. Obesity during pregnancy increases the risk for gestational diabetes, preeclampsia, cesarean delivery, decreased breastfeeding, and maternal mortality. Beyond the perinatal consequences, multiple health complications are associated with obesity. Obesity sequelae include cardiac and endocrine diseases as well as cancer. In trying to come up with strategies to address obesity, breastfeeding can play a critical initiative to reduce obesity. Children who are breastfed are at reduced risk of obesity, 24% lower. A meta-analysis by Arenz et al. 8 reinforces the breastfeeding–obesity reduction association.
A recent systematic review of breastfeeding research conducted by the Agency for Healthcare Research and Quality 9 reported an association between being breastfed and a reduced risk of being overweight or obese in adolescence and adult life.
The incidence of childhood overweight and obesity was lower among infants who were exclusively breastfed for the first 6 months of life. 10 Studies that controlled for exclusivity and duration of breastfeeding showed a protective effect against childhood obesity.
The 2008 Immunization Survey reports that although Hispanics have the highest breastfeeding initiation at 80.4%, 45.1% continue at 6 months, whites have a 74.3% initiation and 43.2% continuation at 6 months, and blacks have a 54.4% initiation and 26.6% 6-month continuation. Asian/Pacific islanders initiate breastfeeding 80.9% and 52.4% continue at 6 months. 11
The role of breastfeeding in reducing obesity is well established. The infant's liver produces proteins that help regulate metabolism: leptin, gherlin, and adiponectin. Leptin inhibits appetite and controls body fatness. When an infant is fed formula instead of breastmilk, insulin levels in the baby are increased. Prolonged insulin response is associated with unfavorable concentrations of leptin.8,12 Among the advantages for the baby breastfeeding cited from the American Academy of Pediatrics are a decrease in illnesses during infancy such as diarrhea, ear infections, and cold/flu, a probable decrease in chronic disease such as diabetes/obesity, a reduction in sudden infant death syndrome, and enhanced cognitive development. For the mother, breastfeeding benefits include increased bonding, lesser risk of certain cancers, and decreased risk of diabetes, weight loss, and remineralization. Overall, breastfeeding benefits for society include lower medical costs for sick infants and reduced parent absenteeism from work. 13
We have seen that among the many benefits of breastfeeding, it can be one strategy to reduce the obesity epidemic in our country, but how do we begin to address the breastfeeding and obesity disparities among those who are impacted the most? I would suggest starting from a point of trying to understand the cultural influences that come into play in their social determinants of health and impact their decisions. The general overview I will make on the various ethnicities is not intended to be absolute and applicable to all people within that culture, but a general starting point of trying to understand the drivers within that culture. Knowing the drivers, we can develop recommendations to breastfeed and take a step to addressing obesity, based on what is important in their culture.
African Americans are 2.5 less likely to breastfeed than whites. Factors influencing their decision to breastfeed include stigma, lack of social support, and beliefs of inconvenience, pain, and sexuality. Cultural knowledge, attitudes, and behaviors prevalent in the community contribute to breastfeeding disparities. 14 Among Latinas, recent immigrants are more likely to initiate and maintain breastfeeding. 15 It is important to note the differences in among the breastfeeding rates in Latin American countries because those are the prevailing attitudes and rates they bring with them when immigrating to the United States. Exclusive breastfeeding for 6-month rates are 37.5% in Mexico, 59% in Bolivia, 97% in Chile, 95% in Columbia, 10% in the Dominican Republic, and 96% in Ecuador. 16
Cultural attitudes among Chinese include the beliefs that they do not produce enough breastmilk and that breastfeeding is something done by the lower class. Older Chinese believe it is good for a baby to be fat. Breastfeeding is seen as very private and difficult to do in public, and formula is often times promoted better than breastmilk. 17 Recently, though, there was a formula scare in China where babies died as a result of formula contaminated with melamine. This scare increased the breastfeeding rates in China.
Taking into account the cultural nuances, education about the importance of breastfeeding is key within all cultures. Education from the healthcare provider, especially the physician, is important because in most cultures the physician is highly respected and viewed as knowledgeable. Cultural sensitivity should be a component in planning the education. Incorporating the patient's language, cultural beliefs, and literacy level will assure increased understanding and higher likelihood for behavior adoption. When the messaging for breastfeeding or health initiatives is reinforced throughout the medical office and community, there is often an understanding that the recommendations are the norm—a social reframing for behavior.
The Surgeon General's Call to Action to Support Breastfeeding identifies barriers to breastfeeding, among which are included lack of knowledge, social norms, employment, health services and health professionals who fail to promote or support the practice, and disparities by race and ethnicity and socioeconomic status. 18 I would like to now highlight some programs we are working on in Los Angeles County to overcome the barriers cited by the Surgeon General.
“Soul Food for Your Baby” 19 is a breastfeeding initiative targeting African Americans. Information obtained from focus groups with African Americans in Los Angeles highlights the importance of education. Ninety-five percent of males who participated in focus groups stated they did not know all of the benefits of breastfeeding. These male participants would encourage and support their partner to breastfeed. The influence of extended family, such as the grandmother, to breastfeed was also among the highlighted results that drive the targets of “Soul Food for Your Baby.” The group in partnership with other breastfeeding groups in Los Angeles provides the African American focus that is often missed when addressing this community.
The Interconception Care Project for California, led by the American Congress of Obstetricians and Gynecologists, California Chapter, and The Preconception Health Council of California and funded by March of Dimes, developed postpartum visit algorithms for providers and companion patient information to address the 10 most common pregnancy and delivery complications identified using ICD-9 discharge code data in California. Obesity is among the 10. The evidence-based provider algorithms and companion culturally sensitive and low literacy patient education materials were developed by a panel of obstetric and health experts throughout California. 20
Provider algorithms were developed so they could be used by nonobstetric providers as well as mid-level providers knowing that patients may miss their postpartum visit and their next medical visit may not necessarily be with their prenatal care provider. The algorithms were reviewed by various types of healthcare providers throughout California to assess their content and utility. Patient handouts, in both Spanish and English, were reviewed by Spanish-speaking and English-speaking patients. The patient brochures provide a simplified explanation of the medical condition and implications for future pregnancies and emphasize the importance of planning the next pregnancy, communication with their healthcare provider, and obtaining early prenatal care. All of the materials are free at www.everywomancalifornia.org to download, print, and distribute free of charge. The prevailing messages for providers and patients are the ABCs for these postpartum mothers: folic acid consumption, breastfeeding, and contraception to be able to plan their future pregnancy in the hopes that any medical complications developed are well managed and addressed. The hope is that providers and patients throughout California will find the materials a valuable resource and use it as a bridge between postpartum health and the future health of mothers and their babies.
LA MOMs (Los Angeles: Managing Obesity in Moms) is a new project whose goal is to deduce obesity among postpartum women in Los Angeles County. In Los Angeles County one in three women of reproductive age is overweight or obese, with a disproportionately higher number of Hispanic and African American women being affected. Maternal overweight and obesity are linked to poor birth outcomes and lower breastfeeding rates. Being overweight or obese before pregnancy increases the likelihood of retaining at least 11 pounds postpartum. Preventive measures and nutritional care should begin preconception and interconception to mitigate overweight problems and other obesity-related pregnancy consequences. As the first teachers in a child's life, parents play a critical role in teaching healthy behaviors and modeling those lifestyles. Focusing on empowering the postpartum mom to obtain a healthy weight will not only impact and improve her health, but potentially her children's as well.
Up until now, little is known about weight management during the postpartum period. Over a 4-year period, LA MOMs will provide culturally sensitive guidance on nutrition, physical activity, and stress reduction, in particular for breastfeeding moms and those who had a surgical or complicated vaginal delivery, with the goal of reducing obesity among postpartum women in Los Angeles County. Breastfeeding education, resources, and support will be offered online and through referrals. The Internet and social media channels will enable women to connect to information, resources, and each other. Upon completion of the project, we hope to create a sustainable, evidence-based postpartum weight management program with a strong social media platform that will be incorporated into groups supporting new moms such as Special Supplemental Nutrition Program for Women, Infants and Children, mothers' groups, health plans, and daycare centers. 21
The National Hispanic Medical Association is working to address obesity through improvement in cultural proficiency in health care, increasing the physician supply in underserved communities, being an active participant in the Let's Move advisory group, and working with the State Hispanic Medical Societies and physician leaders in California and New York. Efforts will focus on developing knowledge to health communications to empower Hispanic physicians to educate their communities over 2 years. 22
Policy drivers for health improvement though are often needed for adoption and change. The Joint Commission is one of those big drivers. Exclusive breastmilk feeding on hospital discharge is one of the five perinatal core measures. 23 The Affordable Care Act Preventive Service for Women is potentially another policy that could improve and support increasing breastfeeding rates and decreasing obesity in women. Breastfeeding support, supplies, and counseling as well as woman visits are among the eight Institute of Medicine–recommended preventive services. 24 All of which are supposed to take effect August 1, 2012, but this is all now dependent on the Supreme Court's ruling.
The disparity in breastfeeding rates and obesity prevalence among women of various ethnicities can only be begun to be addressed if we try and understand their cultural and more importantly the social determinants of health. These come together to impact behavior decisions and ultimately health outcomes. I have shared with you some insight on cultures and programs trying to address these disparities. Understanding the drivers to breastfeed or decision not to breastfeed is the first step in building the bridge between a healthier start in life, despite the circumstances into which we are born, and a future healthy life for the new mom, her baby, and future generations.
Footnotes
Disclosure Statement
No competing financial interests exist.