Breastfeeding: An Unknown Factor to Reduce Heart Disease Risk Among Breastfeeding Women

Abstract

Background:

Breastfeeding confers many health benefits not only to babies but also to their lactating mothers. Breastfeeding is a notable protective factor in the Gail model for breast cancer and is protective for heart disease. Although individuals in the Appalachian region have lower risk of developing breast cancer, their risk of heart disease is elevated compared with the national value for the United States.

Subjects and Methods:

We surveyed 155 predominantly breastfeeding mothers of toddlers under 3 years old, recruited through parenting groups, daycares, and county extension in Appalachian West Virginia. Participants were asked their perceived comparative risks for breast cancer and heart disease and why they felt their risk was higher, same, or lower than that of the general population.

Results:

For breast cancer, 29.7% felt their risk was lower than the general population. For heart disease, 26.5% felt their risk was lower than the general population. Although these risks were highly correlated (p=0.006), there was considerable variability in responses (p<0.03). Qualitative responses for breast cancer risk frequently included breastfeeding (30.3%) and family history (30.3%). Qualitative responses for heart disease noted family history (36.1%) but did not include breastfeeding. A regression analysis found that greater family history, shorter duration of breastfeeding, and fewer pregnancies were associated with greater breast cancer risk perceptions. Family history, lower household income, and current smoking were associated with greater heart disease risk perceptions.

Conclusions:

These well-educated, predominantly lactating women did not know the protective effects of breastfeeding for heart disease. Increased educational efforts about heart disease may be helpful to encourage more women to breastfeed.

Introduction

Many women will be affected by breast cancer and/or heart disease in their lifetimes. Breast cancer is one of leading causes of cancer morbidity in women, and a woman's lifetime risk for developing breast cancer is approximately 12%. However, with advances in screening tests and treatments, the mortality rate for breast cancer has been declining, with over a 30% decrease since 1990.¹ Heart disease is an even greater cause for morbidity in women. Approximately 40% women will have some form of heart disease in their lifetimes.²

Furthermore, various risk factors affect the extent to which women may be at risk for these diseases, and some populations have elevated risk. For example, women from Appalachia have elevated risk for invasive breast cancer and for breast cancer mortality, as well as for heart disease morbidity and mortality.^3,4 Appalachia is a geographically and politically designated region, comprising 13 states along the Appalachian Mountains in the eastern United States, with West Virginia being the only state entirely within Appalachia.⁵ Appalachia has been noted for several disparities: having lower educational attainment, higher poverty rates, and more counties that are medically underserved than other regions of the country.⁵ Clearly, this elevated risk and the medically underserved population merit further consideration in order to understand their perceptions of the underlying risk and protective factors for breast cancer and heart disease.

Although risk for breast cancer and heart disease increase with age,^6,7 mothers of young children are not only making decisions to improve their own health, but also to improve the health of their families, and thus are a critical population for study. It is notable that although literature reviews have called into question the true protective effects of breastfeeding for breast cancer,⁸ breastfeeding has been considered a key protective factor for breast cancer in mothers, with longer length of breastfeeding having a more protective effect.^9,10 Similarly, some have questioned the association of breastfeeding in mothers and heart disease,¹¹ although more recent studies show a protective effect.^12,13 In spite of this potentially protective effect, West Virginia is among the states with the lowest rates of breastfeeding,¹⁴ increasing the risk of negative health outcomes. Young women are also making health decisions for their families about energy balance (diet and exercise, as well as associated obesity),¹⁵ which are key risk factors for breast cancer and heart disease. Here again, Appalachia has elevated risk from having higher rates of obesity. Furthermore, West Virginia has the highest rate of smoking in the country,¹⁶ and smoking is an established risk factor for cardiovascular disease and breast cancer.^17,18 Finally, both breast cancer and heart disease may have a strong hereditary component, with family history being an important risk factor^19,20; however, even in the case of familial disease, personal behavior can have an important impact on chances of having disease and consequently on health outcomes.

Several studies indicate that individuals' perceptions of the risk of breast cancer and heart disease are inaccurate. For breast cancer, most studies find that women have inaccurate perceptions of risk,²¹ with some reporting underestimates²² and others reporting overestimates.²³ Many studies explored the role of family history, which plays a critical role in risk perception, often increasing risk.²⁴ We identified only one study conducted in Korea that explored the role of history of breastfeeding for its quantitative impact on perceptions, finding that breastfeeding was associated with underestimates of breast cancer risk.²⁵ Qualitative studies of the role of breastfeeding in breast cancer risk in Hispanic American and African American women found that some believed that breastfeeding could actually increase the risk of breast cancer.²⁶ Overall, we identified few studies of breast cancer risk perceptions and breastfeeding in women, particularly among women who may have been at an age to be currently or recently completing breastfeeding. Similarly, women had inaccurate perceptions of heart disease,²⁷ with some overestimating²⁸ and some underestimating their risk of heart disease.²⁹ Family history and being overweight were two common associations with perceived risk.³⁰ History of breastfeeding appears largely unexplored for perceptions of heart disease risk.

Along with considering each disease separately, recent comparisons of risk perceptions for breast cancer and heart disease were rare. Recent studies have found that women had higher perceived risk of breast cancer than heart disease,^31,32 but a prior study found the opposite.³³ Having a family or friend with the disease elevated a woman's perceived risk of breast cancer and heart disease.³⁴ Furthermore, among smokers, only 29% believed their risk of myocardial infarction and 40% believed their risk of cancer (not specifically breast cancer) were elevated,³⁵ echoed by other studies finding underestimated risk.³⁶ Most of these comparative studies were conducted nearly 20 years ago, when the population had a different objective risk profile and focused on a different population. Furthermore, we identified no studies to compare risk perceptions qualitatively to understand which factors women felt impacted their risk.

Thus, the purpose of the current study is to understand how perceptions of breast cancer and heart disease differ and the beliefs underlying this risk, in predominantly breastfeeding mothers of young children in an elevated risk population.

Subjects and Methods

Participants

Eligibility for the current study included women who had at least one child under 3 years of age, who were from the state of West Virginia (and hence Appalachian), and who could read and write in English. For the initial cognitive interviewing portion of the study (n=8), a convenience sample was recruited by word of mouth from investigators in the study. The remaining participants were recruited through social media (e.g., Facebook parenting groups in West Virginia), listservs, flyers in the community (e.g., daycares, doctor's offices, a Women, Infants, and Children agency), and a newsletter from West Virginia University Extension.

Procedures

The larger survey was developed as a part of a class project to develop surveys in health research, with class members fully invested in the critique of survey items and the promotion of the survey. Once a final survey was drafted, the Institutional Review Board reviewed and approved the study. This survey was then reviewed in the context of in-person cognitive interviews conducted by members of the class. Individuals participating in these in-person interviews received a university-themed gift item for participation. Modifications were discussed in a class meeting, and revisions were submitted to and approved by the Institutional Review Board. The final survey was launched online and promoted through a variety of social and print media.

Measures

Previously established and newly developed items were included for the current study. Demographics included age in years, annual household income, education level, race and ethnicity, smoking status, smoking while pregnant, rural status, perceived Appalachian status,³⁷ and whether participants were members of any religious group. In addition, we asked their prior number of pregnancies, number of children, whether they had ever breastfed, and how long they breastfed. Negative affect was assessed with the Profile of Mood States, with a 5 point response scale ranging from not at all to very much.³⁸ Finally, comparative risk was assessed for breast cancer and heart disease with a 3 point response scale ranging from lower to higher, and participants were asked why they felt their risk was the same, higher, or lower than the general population.³⁷

Plan for analysis

We used a concurrent analytical approach to the analysis of qualitative and quantitative data. In preparation for qualitative analysis, a list of all open-ended responses given by participants in response to the two open-ended questions assessing reasons underlying breast cancer and heart disease risk perceptions was prepared. This list was then coded by the first and third authors, who were blinded to demographic status of participants. First, the range and nature of responses were reviewed. Then, overarching themes were determined, a method consistent with Grounded Theory.³⁹ For quantitative analyses, perceived risk of breast cancer and perceived risk of heart disease were compared with correlations, nonparametric tests, and paired t tests. Forward stepwise regressions were conducted for the outcomes of perceived risk of breast cancer and perceived risk of heart disease. Predictors included age, education, income, ethnicity, race, employment status, Appalachian identity, number of pregnancies, number of children, history of breastfeeding, length of breastfeeding, current smoker, ever smoked, smoked while pregnant, depression, anxiety, and qualitative reports of family history. Variables were selected in order based on degree of correlation with the outcome variable and included in the model if p<0.05. Variables not meeting this criterion (p<0.05) were not considered in the model. As all variables remained p<0.05 at all steps of the analysis, no variables were removed from the model after entry.

When adding all variables into the respective models, our sample size for analysis dropped from n=155 to n=120 due to missing data. These missing data were largely due to a skip pattern for two of the smoking variables that was quickly remedied at the initiation of the study. Therefore, we conducted two analyses each for breast cancer and heart disease risk perception, one including the smoking questions and one excluding the smoking questions.

Results

In total, 233 entries were made in the online survey. Duplicate participants were identified by participant's date of birth and Internet protocol address, and the entry with the most complete dataset was retained in the data. Entries were also removed if no children were included or if children were over 36 months of age, as these women were ineligible for the larger study. This resulted in a sample of 179. Of these, 24 were removed from analysis as they did not have risk information, likely due to the location of the items at the end of the larger survey (n=155).

Table 1 includes demographics of the sample. Most women had one or two pregnancies (71.6%), and the average number of children per participant was 1.7 (standard deviation [SD]=0.9). Most (99.2%) reported access to a pediatrician. The majority of the women had breastfed their children (93.5%), and of those who breastfed, approximately a third (34.3%) nursed less than 6 months, most (56.0%) nursed 6 months to less than 2 years, and some (9.8%) nursed 2 years or more.

Table 1.

Demographics of the Sample

Demographic	Value
Age (years)^a	32.6 (4.6)
Hispanic/Latina
Yes	1.3%
No	98.7%
Race
White	96.1%
American Indian/Alaskan Native	1.3%
Black/African American	1.9%
Native American/Pacific Islander	0.6%
Self-identify as Appalachian
Yes	40.3%
No	59.7%
Education
GED/high school diploma or less	3.4%
Some college or technical school	21.7%
Bachelor's degree	27.9%
Graduate or professional school	46.9%
Income
Less than $50,000	17.3%
$50,000 or more	72.7%
Employment
Full-time	61.9%
Other	38.1%
Number of children^a	1.7 (0.9)
Access to a pediatrician
Yes	99.2%
No	0.8%
Smoking status
Never	5.2%
Former	25.0%
Current	55.0%
Not reported	14.8%
History of breastfeeding
Yes	93.5%
No	6.5%
Length of breastfeeding
<6 months	34.3%
6 months to >2 years	56.0%
2 years or more	9.8%
Anxiety (1=not at all to 5=very much)^a	2.2 (1.0)
Depression (1=not at all to 5=very much)^a	1.6 (0.9)
Perceived risk of breast cancer (1=lower to 3=higher)^a	1.9 (0.7)
Perceived risk of heart disease (1=lower to 3=higher)^a	2.0 (0.8)

Data are mean (standard deviation) values.

For breast cancer, 29.7% perceived that their risk was lower than the general population. For cardiovascular disease, 26.5% perceived that their risk was lower than the general population. Although these risks were highly correlated (r=0.2, p=0.006), with 44.5% reporting consistent risk perceptions for both diseases, there was considerable variability in responses (χ²=11.0, p<0.03). For example, some perceived that their risk of heart disease was higher, although they also believed their risk of breast cancer was lower than the general population (n=10). Conversely, some perceived that their risk of heart disease was lower, although they also believed risk of breast cancer was higher than the general population (n=6). Overall, perceived risk of breast cancer (mean=1.9, SD=0.72) did not differ from that of heart disease (mean=2.0, SD=0.75) in this sample.

Qualitative responses for breast cancer risk were quantified in terms of frequency of report. Family history was frequently mentioned as a risk factor for breast cancer, with 30.3% reporting a family history and 27.7% reporting no family history. Women also reported breastfeeding (30.3%) as an important protective factor for breast cancer risk. Some women reported that they felt at risk because everyone can get it (10.3%), because they were women (1.3%), or because they had large breasts (1.3%). Notable modifiable risk factors mentioned were diet (7.7%), smoking status (0.6%), being overweight (.6%), and general lifestyle (0.6%). Screening also made some women feel at lower risk of breast cancer (1.9%). Hormonal factors such as pregnancy (0.6%) and early menses (0.6%) were mentioned. In addition, some women reported that less scientifically established behaviors made them feel less at risk, such as not wearing deodorant with aluminum, eating organic foods, using natural hygiene products, and avoiding meat (2.6%).

Similarly, in the case of heart disease, 36.1% reported that their family history increased their risk, and 14.8% reported no family history, decreasing their risk. Again, some women felt at risk because everyone can get it (4.5%). Modifiable risk factors also played a role in heart disease risk, including having a good (18.7%) or bad (5.8%) diet, being overweight (7.7%) or at a healthy weight (1.9%), smoking (3.9%) or not smoking (2.6%), screening (3.2%), having a healthy lifestyle (3.9%), and feeling stressed (0.6%). Some mentioned biochemical factors placing them at elevated risk such as hyperlipidemia (1.9%). Breastfeeding was not mentioned.

Chi-squared analysis compared those who had missing smoking data due to an incorrect skip pattern and those who did not. Those who had missing data were less likely to be employed full-time outside of the home (χ²_6,155=16.54, p=0.01), which is understandable as the survey skip pattern for the smoking items was corrected by the evening when most women working outside of the home would finish their workday and could complete the survey.

Forward stepwise regression models were conducted for the outcomes of breast cancer and cardiovascular disease risk. For perceived risk of breast cancer, the change in sample size due to missing smoking variables did not affect the overall model (F_3,141=44.32, r²=0.49, 95% confidence interval [CI]=1.66, 2.23); in both cases, greater family history (adjusted β=0.65, 95% CI=0.84, 1.24, p<0.001), shorter duration of breastfeeding (adjusted β=−0.28, 95% CI=−0.21, −0.08, p<0.001), and fewer pregnancies (adjusted β=0.19, 95% CI=0.03, 0.17, p=0.006) were associated with higher perceived risk. However, for perceived risk of heart disease in the full sample, only family history was associated with perceived risk (p<0.001). When the two additional smoking variables were added (decreasing the sample size) to the model (F_3,₁₁₉=21.40, r²=0.34, 95% CI=1.19, 3.49), greater family history (adjusted β=0.55, 95% CI=0.63, 1.10, p<0.001), lower household income (adjusted β=0.21, 95% CI=0.03, 0.18, p=0.007), and current smoking (adjusted β=−0.17, 95% CI=−1.20, −0.07, p<0.03) were associated with higher perceived risk.

Discussion

The purpose of this study was to understand perceived risk of breast cancer and heart disease in mothers of young children, most of whom were breastfeeding. As a part of this risk, we sought to understand the factors that played a role in whether or not they felt at risk for breast cancer and heart disease. To begin, although we sought women who were from Appalachia and all indicated a zip code in Appalachia, approximately half did not indicate that they were Appalachian, which is higher than in a previous study by Reiter et al.⁴⁰ We believe this may be due to (1) lack of awareness that they live in Appalachia or (2) short duration of living in the area.

Furthermore, even though the risk of heart disease is higher than that of breast cancer, we found that women did not differ in their perceived risk of breast cancer versus heart disease. Thus, our results are consistent with previous studies indicating that women overestimated their risk of breast cancer in comparison with heart disease.³¹ However, although the two perceptions were similar in terms of overall means and were highly correlated, some reported higher perceptions of breast cancer, and others reported higher perceptions of heart disease. Thus, these results are important for two reasons: (1) they reveal the overall inaccuracies of women in their comparative perception of breast cancer and heart disease risk, and (2) the perceived risks for these two diseases were not synonymous and are worthy of unique consideration.

Our quantitative analyses of perceived risk of breast cancer and heart disease were generally consistent with the risk factors identified in our open coding. Clearly, women with a family history of breast cancer and women who breastfed for a shorter period of time felt they were at higher risk of breast cancer. This is consistent with previous research.^24,25 However, the quantitative finding that women with fewer pregnancies perceived their risk of breast cancer as greater was rarely mentioned in the qualitative data. Indeed, only one woman reported in the open-ended data that she felt at elevated risk due to having fewer pregnancies. Women who have no or fewer pregnancies are at objectively higher risk of breast cancer, according to the Gail model.⁴¹ Rather than understanding that their risk was higher due to having fewer pregnancies, women may instead be thinking in terms of fewer pregnancies as equating with fewer opportunities to breastfeed. Another explanation might be that women view having fewer pregnancies as a risk factor, but other factors (e.g., family history) were more important. Future research can clarify this mechanism.

In the case of cardiovascular disease, our results changed as a result of the loss of 22 women who had missing values for two smoking variables. Having a family history of heart disease was consistently associated with higher perceived risk of heart disease. However, when the smoking variables were added, being a current smoker and having lower household income were associated with perceived risk of heart disease. Smoking is a clear risk factor for cardiovascular disease,^17,18 but an early literature review from Weinstein⁴² found that smokers minimized the risk of smoking and its association with disease. Our findings on breast cancer perceptions support the minimization of smoking risk, but our findings on heart disease indicate that women believe smoking increases risk. Progress has been made in this area, increasing the link between heart disease and smoking, perhaps due to greater attention to the risk of stroke with oral contraceptives,⁴³ counseling for which may routinely occur at pharmacies.

Although these women reported that breastfeeding was a protective factor for breast cancer, they did not report that breastfeeding was a protective factor for heart disease in the qualitative data. Furthermore, breastfeeding was not found to be associated with perceived risk of heart disease in the quantitative analysis. Although breastfeeding is generally believed to be protective for heart disease,¹² this message does not appear to be understood by the larger public. One possible explanation is that heart disease is still seen as a man's disease and that breastfeeding and breast cancer are closely associated as both affect the breast. Important to note is that this is a relatively well-educated group of women, nearly all of whom had tried to breastfeed and many of whom engaged in extended breastfeeding. Thus, if these women are not getting the message about the benefits of breastfeeding for heart disease, it is unlikely that women with fewer resources and less health literacy would understand the heart risk reduction potential of breastfeeding. In turn, this breast-centric focus may contribute to the discomfort and sexualization some may associate with breastfeeding.

Strengths and limitations to the current study should be noted. To begin, we used an online survey that resulted in a well-educated sample of Appalachian women, most of whom had at least attempted to breastfeed. Thus, this sample may not be representative of the larger population. Our weakness of having well-educated women is also a strength: our findings indicate that even among well-educated, breastfeeding women, the potential cardioprotective effects of breastfeeding are not well known, a result we expect to be more pronounced in the broader population. Furthermore, we did not conduct individual in-person interviews with these women, which may have resulted in less-rich qualitative data. However, we did conduct cognitive interviews with a diverse sample of women, and the survey was reviewed by multiple graduate students, some of whom were mothers themselves.

Conclusions

In this well-educated sample of predominantly lactating women, none reported the protective effects of breastfeeding for cardiovascular disease. Educational efforts to promote awareness about the cardioprotective effects of breastfeeding may help to encourage women to breastfeed (i.e., breastfeeding is not only about the breast, it is about the functioning of the entire body for both parents and infants), moving away from a breast-centric and gendered understanding of breastfeeding. This message that breastfeeding reduces risk of heart disease goes hand-in-hand with promoting awareness that women can get heart disease like men and, as such, may promote awareness of two important issues for women's health.

Footnotes

Disclosure Statement

No competing financial interests exist.

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