Breastfeeding and Maternal and Child Cardiometabolic Outcomes 10

Abstract

Background:

Breastfeeding can improve long-term maternal and child cardiometabolic outcomes, but many of the cardiometabolic outcomes remain understudied.

Objective:

To examine the association between breastfeeding and maternal and child cardiometabolic outcomes 10–14 years after delivery.

Study Design:

A secondary analysis of the prospective Hyperglycemia and Adverse Pregnancy Outcome Follow-Up Study (2013–2016). The exposure was any breastfeeding. The primary outcomes were maternal and child disorders of glucose metabolism assessed separately and defined as one of the following: prediabetes (impaired fasting glucose [100–125 mg/dL] or impaired glucose tolerance [2-hour plasma glucose of 140–199 mg/dL]) or type 2 diabetes mellitus. Secondary outcomes included maternal and child hypertension and dyslipidemia (low-density lipoprotein ≥103 mg/dL, total cholesterol ≥200 mg/dL, or triglycerides ≥200 mg/dL), and child adiposity (body fat percentage >85th). Multivariate logistic regression was used to examine the association between breastfeeding and maternal and child cardiometabolic outcomes.

Results:

Of 4,685 assessed maternal–child dyads, 79.7% reported breastfeeding. The risk of maternal disorders of glucose metabolism did not differ by breastfeeding status (24.1% versus 24.5% with versus without breastfeeding, adjusted relative risk [aRR] 1.00, 95% confidence interval [CI] 0.88–1.14). The risk of childhood disorders of glucose metabolism was lower with breastfeeding (10.7% versus 13.7%, aRR: 0.76, 95% CI: 0.63–0.92). With regard to secondary outcomes, mothers who breastfed had a lower rate of dyslipidemia (29.4% versus 32.8%, aRR: 0.88, 95% CI: 0.80–0.98). Offspring that were breastfed had lower rates of child adiposity (13.6% versus 17.5%, aRR: 0.82, 95% CI: 0.70–0.96). There was no difference in the rate of maternal hypertension by breastfeeding status. In the subgroup of mothers with gestational diabetes, breastfeeding was associated with a lower risk of child hypertension (aRR: 0.66, 95% CI: 0.45–0.99) and a lower risk of child adiposity measured by skinfold sum > 85th percentile (aRR: 0.67, 95% CI: 0.49–0.92).

Conclusions:

In an international prospective cohort, breastfeeding was associated with a reduced risk of maternal hypercholesterolemia and disorders of glucose metabolism and adiposity in the offspring.

Community Brief

A. Why was this study conducted?

Cardiometabolic risk factors, such as hypertension, obesity, diabetes, and dyslipidemia, are leading contributors to morbidity and mortality. Breastfeeding can prevent cardiometabolic risk factors in the postpartum period. However, more prospective data are needed about the association between breastfeeding and long-term maternal and child cardiometabolic outcomes.

B. What are the key findings?

In an international prospective cohort of 4,832 mother–child pairs, breastfeeding was associated with lower odds of maternal dyslipidemia and child dysglycemia and adiposity 10–14 years after delivery.

C. What does this study add to what is already known?

These results from a large prospective international cohort emphasize the benefits of breastfeeding toward improving multiple measures of maternal and child cardiovascular health.

Introduction

Cardiometabolic risk factors, such as hypertension, obesity, diabetes, and dyslipidemia, are leading contributors to morbidity and mortality.^1,2 These cardiometabolic risk factors can be prevented with lifestyle changes and health behaviors in the postpartum period, including breastfeeding.^3,4 The World Health Organization recommends exclusive breastfeeding for the first 6 months of life⁵ because of strong evidence of short-term health benefits for the infant, including lower rates of gastroenteritis,⁶ respiratory disease,^6,7 acute otitis media,⁸ sepsis,⁹ and sudden infant death syndrome.¹⁰ There are also cardiometabolic benefits for the mother with improvements in glucose tolerance and insulin sensitivity¹¹ that translates to a decreased risk of diabetes^12–14 and gynecological cancers.^15–17

To date, there is limited evidence about the association between breastfeeding and child cardiometabolic outcomes, including measures of obesity, cholesterol, and blood pressure.^18–22 In addition, further data are needed to confirm the association between breastfeeding and long-term maternal cardiometabolic outcomes beyond diabetes, including cholesterol and blood pressure.^23–26 Date from prospective birth cohorts with long-term maternal and child cardiometabolic outcomes are needed.

The objective of the current analysis was to examine the association between breastfeeding and maternal and child cardiometabolic outcomes 10–14 years after delivery in the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Follow-Up Study (HAPO FUS). We hypothesized that breastfeeding would be associated with improvements in multiple measures of cardiometabolic outcomes for both the mother and child.

Methods

Study setting

This was a secondary analysis of the HAPO FUS,²⁷ which was a multinational, prospective follow-up cohort at 10–14 years after delivery of a subset of mother–child pairs at 10 of the original HAPO study centers between 2013 and 2016. The HAPO FUS assessed the impact of pregnancy dysglycemia on long-term maternal and child cardiometabolic outcomes.^27,28 The protocol was approved by each center’s Institutional review board (IRB). Participants provided informed consent. This analysis received an exemption for IRB review from the Medical College of Wisconsin IRB (PRO00047484).

Participants

Eligibility in the HAPO FUS included participants who were blinded to their gestational diabetes mellitus (GDM) screening results, gestational age at delivery ≥37 weeks’ gestation in the index HAPO pregnancy, and no major neonatal malformations or fetal or neonatal death. Those diagnosed with type 2 diabetes were excluded from the original study. For the current analysis, we excluded participants who were missing breastfeeding status.

Procedures

At the time of the follow-up study visit 10–14 year after delivery, children completed measurements of blood pressure, height, weight, waist and mid-arm circumference, skinfolds, body size, an oral glucose tolerance test (OGTT), and collection of blood for fasting lipids. The mothers underwent blood pressure checks and a 2-hour 75-g OGTT. The mothers also completed a questionnaire regarding demographics and lifestyle characteristics.

Exposure

The exposure was breastfeeding status. Mothers at the follow-up study visit completed questionnaires including yes/no response to breastfeeding after the HAPO pregnancy. Information on breastfeeding intensity, exclusivity, and duration was not collected in the original study.

Outcomes

The primary outcome was disorders of maternal and childhood glucose metabolism measured separately. Disorders of glucose metabolism included both prediabetes and type 2 diabetes, which was defined as one of the following: prediabetes (impaired fasting glucose, defined by the American Diabetes Association [ADA] as fasting plasma glucose [FPG] of 100–125 mg/dL, or impaired glucose tolerance [IGT], defined by the ADA as 2-hour plasma glucose of 140–199 mg/dL after 75-g OGTT) or diagnosis of type 2 diabetes mellitus (defined by the ADA as FPG of ≥126 mg/dL and/or 2-hour plasma glucose value ≥200 mg/dL).²⁹

Secondary maternal outcomes included hypertension (taking antihypertensive medication or as systolic blood pressure of ≥140 mmHg or diastolic blood pressure of ≥90 mmHg), dyslipidemia (one or more of the following: low-density lipoprotein ≥103 mg/dL, total cholesterol ≥200 mg/dL, or triglycerides ≥200 mg/dL). Secondary child outcomes included hypertension (blood pressure at >85th percentile based on normative pediatric blood pressure tables³⁰), dyslipidemia (same criteria as maternal hyperlipidemia), and adiposity (body fat >85th percentile, midpoint waist circumference >85th percentile, sum of skinfolds [subscapular, triceps, and suprailiac] >85th percentile, or body mass index >85th percentile).³¹

Statistical analysis

Data were summarized using frequencies and counts for categorical variables and median with interquartile range for continuous variables. Univariable analyses compared baseline demographic characteristics and cardiometabolic risk factors with outcomes stratified by breastfeeding exposure groups using t test or Mann–Whitney for continuous variables, and chi-square, or Fisher’s exact test for categorical variables. Multivariable logistic regression models were used to determine the association between breastfeeding and maternal and child cardiometabolic outcomes, and adjusted for baseline pregnancy maternal age, hypertensive disorders of pregnancy, and maternal tobacco and alcohol use. Child outcomes of disorders of glucose metabolism and dyslipidemia were also adjusted for birthweight and BMI at the follow-up visit. These variables were selected for inclusion a priori based on a conceptual understanding of confounding between breastfeeding and cardiometabolic outcomes as well as statistical significance in univariate analysis (p < 0.05).

In secondary analyses, two subgroup analyses were performed among mothers with prepregnancy BMI ≥ 30 kg/m² and among those who had a GDM diagnosis (effect modification or interaction).³² All statistical tests were two-sided, and α < 0.05 was considered statistically significant. All analyses were conducted using RStudio 4.0.2 (R Core Team, 2020, Boston, MA).

Results

Of 4,832 participants in the HAPO FUS who completed all or part of the follow-up studies, breastfeeding data were collected and available for 4,685 (97.0%) who were included in the current analysis (Fig. 1). A total of 3,735 (79.7%) mothers reported any breastfeeding and 950 (20.3%) reported no breastfeeding.

FIG. 1.

Flowsheet of participants included in the secondary analysis.

Mothers had similar rates of GDM as well as BMI at enrollment and follow-up, regardless of breastfeeding status (Table 1). The frequency of tobacco use in pregnancy and HDP was lower in the breastfeeding group (p < 0.001 for both). Offspring who were breastfed were delivered at a later gestational age (p = 0.04) and had higher birthweight (p = 0.02).

Table 1.

Maternal and Child Characteristics During Pregnancy and Follow-Up Visit by Breastfeeding Status

	No breastfeeding (n = 950)	Breastfeeding (n = 3,735)	p
Maternal characteristics
Pregnancy data
GDM by IADPSG	129 (13.6)	538 (14.4)	0.55
Age at OGTT (years)	30.0 (25.5, 33.7)	30.7 (26.1, 34.2)	0.02
Ancestry group			<0.01
Asian	321 (33.8)	853 (22.8)
Non-Hispanic Black	52 (5.5)	681 (18.2)
Hispanic	83 (8.7)	404 (10.8)
Non-Hispanic White	471 (49.6)	1733 (46.4)
Other	23 (2.4)	64 (1.7)
Prepregnancy body mass index (kg/m²)	26.7 (24.0, 30.0)	26.6 (24.1, 29.9)	0.69
Alcohol use	90 (9.5)	310 (8.3)	0.28
Tobacco use	123 (12.9)	120 (3.2)	<0.01
Family history of diabetes	394 (41.5)	1585 (42.4)	0.62
Family history of hypertension	667 (70.2)	2502 (67.0)	0.06
10- to 14-year follow-up data
Age (years)	41.4 (37.1, 45.4)	42.4 (38.8, 45.9)	0.01
Body mass index (kg/m²)	25.7 (22.5, 29.9)	25.7 (22.6, 30.1)	0.70
Tobacco use	146 (15.4)	222 (5.9)	<0.01
Alcohol use	218 (22.9)	1306 (35.0)	<0.01
Infant characteristics
At birth
Sex			0.12
Male	507 (53.4)	1885 (50.5)
Female	443 (46.6)	1850 (49.5)
Gestational age at delivery	39.7 (38.9, 40.7)	39.9 (39.0, 40.7)	0.04
Birthweight	3340 (3035, 3664)	3380 (3070, 3690)	0.02
Follow-up visit
Age (years)	11.3 (10.5, 12.2)	11.4 (10.6, 12.2)	0.81

All data presented as n (%) or median (IQR).

Bolded results signify statistically significant findings (p < 0.05).

GDM, gestational diabetes; IADPSG, International Association of the Diabetes and Pregnancy Study Group; LDL, low-density lipoprotein; OGTT, oral glucose tolerance test.

The risk of maternal disorders of glucose metabolism did not differ by breastfeeding status (24.1% in the breastfeeding group versus 24.5% in the nonbreastfeeding group; adjusted relative risk [aRR]: 1.00, 95% confidence interval [CI]: 0.88–1.14) (Table 2). In contrast, the risk of child disorders of glucose metabolism was significantly lower with breastfeeding (10.7% versus 13.7%; aRR: 0.76, 95% CI: 0.63–0.92) (Table 2).

Table 2.

Maternal and Child Cardiometabolic Outcomes with Breastfeeding

	No breastfeeding (n = 950)	Breastfeeding (n = 3,735)	p	Relative risk (95% CI)	Adjusted relative risk^a (95% CI)
Maternal outcomes
Disorder of glucose metabolism	233 (24.5)	901 (24.1)	0.84	0.99 (0.87, 1.12)	1.00 (0.88, 1.14)
Secondary outcomes
Hypertension	92 (9.7)	319 (8.5)	0.26	0.88 (0.71, 1.10)	0.96 (0.77, 1.20)
Elevated LDL (≥130 mg/dL)	207 (21.8)	742 (19.9)	0.17	0.91 (0.79, 1.04)	0.92 (0.81, 1.06)
Elevated total cholesterol (≥200 mg/dL)	312 (32.8)	1099 (29.4)	0.04	0.89 (0.81, 0.99)	0.88 (0.80, 0.98)
Elevated triglycerides (≥200 mg/dL)	46 (4.8)	138 (3.7)	0.11	0.76 (0.55, 1.06)	0.87 (0.62, 1.21)
Child outcomes
Disorder of glucose metabolism	130 (13.7)	400 (10.7)	<0.01	0.75 (0.62, 0.90)	0.76 (0.63, 0.92)
Secondary outcomes
Hypertension^b	155	510	0.04	0.84 (0.71, 0.99)	0.86 (0.73, 1.02)
Elevated LDL ≥130 mg/dL	45 (4.7)	177 (4.7)	0.76	0.95 (0.69, 1.31)	0.96 (0.69, 1.33)
Elevated total cholesterol ≥200 mg/dL	81 (8.5)	273 (7.3)	0.10	0.82 (0.65, 1.04)	0.86 (0.68, 1.11)
Elevated triglycerides ≥200 mg/dL	83 (8.7)	265 (7.1)	0.04	0.78 (0.61, 0.98)	0.83 (0.66, 1.06)
Body fat percentage >85%	166 (17.5)	609 (13.6)	<0.01	0.79 (0.67, 0.92)	0.82 (0.70, 0.96)
Midpoint waist circumference >85%	161 (16.9)	529 (14.2)	0.04	0.84 (0.71, 0.99)	0.86 (0.73, 1.01)
Skinfold sum >85%	162 (17.1)	519 (13.9)	0.01	0.81 (0.89, 0.96)	0.87 (0.74, 1.020
Body mass index >85%tile	283 (30.0)	993 (26.6)	0.05	0.89 (0.80, 1.00)	0.95 (0.85, 1.07)

All data presented as n (%).

Bolded results signify statistically significant findings (p < 0.05).

Maternal outcomes were adjusted for age at oral glucose tolerance test, hypertensive disorders of pregnancy and tobacco, and alcohol use at follow-up visit. Infants’ outcomes were adjusted for maternal age at oral glucose tolerance test, hypertensive disorders of pregnancy, maternal tobacco, and alcohol use at follow-up, neonatal birthweight, and offspring BMI at follow-up visit.

Based on normative pediatric blood pressure tables published by the American Academy of Pediatrics in 2004 “Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.”

CI, confidence interval; LDL, low-density lipoprotein.

With regard to secondary maternal outcomes, breastfeeding was associated with a lower risk of maternal dyslipidemia (29.4% in the breastfeeding group versus 32.8% in the nonbreastfeeding group; aRR: 0.88, 95% CI: 0.80–0.98) (Table 2). There was no difference in the risk of hypertension by breastfeeding status (Table 2).

With regard to secondary infant outcomes, breastfeeding was associated with a lower risk of adiposity as measured by body fat percentage >85th percentile (17.5% in the nonbreastfeeding group versus 13.6% in the breastfeeding group; aRR: 0.82, 95% CI: 0.70–0.96) (Table 2).

In subgroup analyses, among mothers with prepregnancy BMI ≥30 kg/m², there was no significant association between breastfeeding and long-term maternal outcomes (Supplementary Table S1). However, when analyzing offspring outcomes, breastfed offspring in the subgroup of mothers with prepregnancy BMI ≥30 kg/m² had a lower risk of disorders of glucose metabolism (15.4% in the nonbreastfeeding group versus 11.1% in the breastfeeding group; aRR: 0.68, 95% CI: 0.48–0.97; Supplementary Table S1). In the subgroup of mothers with GDM, breastfeeding was associated with lower risk of child hypertension (aRR: 0.66, 95% CI: 0.45–0.99) and a lower risk of adiposity measured by skinfold sum > 85th percentile (aRR: 0.67, 95% CI: 0.49–0.92) (Supplementary Table S2).

Discussion

Principal findings

Breastfeeding was associated with a lower risk of maternal dyslipidemia, childhood dysglycemia, and adiposity 10–14 years after delivery. The reported uptake of breastfeeding was high in this international prospective cohort.

Results in the context of what is known

While the public health impact of breastfeeding for improved infant and child health is widely acknowledged, there is a need to focus on examining individual cardiometabolic outcomes associated with breastfeeding. The two maternal outcomes that have most frequently been examined with breastfeeding are lifetime cardiovascular disease (CVD) and diabetes.^23,33,34 When examining the risk of type 2 diabetes, a longitudinal multicenter US study found that longer breastfeeding duration was associated with a lower risk of diabetes incidence both in patients with and without GDM.³⁵ A meta-analysis of 206,204 participants showed that breastfeeding for more than 12 months was associated with a relative risk reduction of 30% of type 2 diabetes.³⁶ In addition, a systematic review found a lower risk of maternal hypertension with a minimum duration of breastfeeding of at least 1 month.³⁷ In contrast, a 2018 the Agency for Healthcare Research Comparative Effectiveness Review summarized findings from five cohort studies involving 441,989 women and indicated that while an extended period of breastfeeding was linked to a decreased risk of maternal hypertension, there was insufficient evidence to establish a clear association between breastfeeding and CVD.²³ A more recent systematic review of eight large observational studies concluded that any breastfeeding was associated with an approximately 10% lower risk of CVD or stroke.¹⁴ Finally, our analysis confirmed long-term benefits of breastfeeding toward reducing maternal dyslipidemia. Possible explanations for this association include increases in metabolic expenditure, lipid metabolism, and excretion of triglycerides and cholesterol in milk.³ However, our analysis did not demonstrate the association between breastfeeding and maternal hypertension, diabetes, or prediabetes. The impact of breastfeeding on these outcomes may diminish with age and may be related to the length and exclusivity of breastfeeding³⁸ that requires further study.

The evidence supporting the connections between breastfeeding and long-term cardiovascular outcomes in the offspring is less robust.¹⁸ In the current study, we found lower rates of disorders of glucose metabolism and adiposity among offspring who were breastfed. A meta-analysis found lower risk of childhood diabetes after breastfeeding.³⁹ However, this analysis did not control for the offspring’s body mass index (BMI). With regard to breastfeeding exposure and offspring overweight or obese, a systematic review demonstrated that breastfeeding had a protective effect against early childhood overweight and obesity.⁴⁰

What our study adds to what is already known

While prior studies have primarily focused on the impact of breastfeeding on maternal diabetes and CVD risk, our findings expand this understanding to other cardiometabolic outcomes, including dyslipidemia. Second, we observed that breastfeeding was associated with lower rates of childhood dysglycemia even after controlling for BMI—a finding that underscores breastfeeding’s independent contribution to metabolic health in offspring. Third, our results confirm the protective association between breastfeeding and lower offspring adiposity.

Clinical and research implications

In an environment of rising rates of adverse cardiometabolic outcomes globally, promoting breastfeeding as a mean to reduce their risk can have broad public health implications for maternal and child health. By encouraging breastfeeding initiation and duration, healthcare clinicians and policymakers can work toward reducing the overall burden of adverse cardiometabolic health. Since the decision of a mother to start and continue breastfeeding may be impacted by the benefits to the offspring, incorporating the evidence of long-term reduction of child adiposity and dysglycemia in promoting breastfeeding uptake. Furthermore, it is important to identify pregnant and postpartum cohorts that can be leveraged to study long-term effects of breastfeeding, including by duration and exclusivity, on cardiometabolic outcomes, as well as social determinants of health and other lifestyle and behavioral factors that impact the decision to breastfeed. Another critical research direction is investigating the relative impact of breastfeeding on cardiometabolic outcomes among high-risk subgroups who have experienced an adverse pregnancy outcome, such as hypertensive disorders of pregnancy⁴¹ or GDM,⁴² and who may be less likely to breastfeed and at higher risk of adverse long-term outcomes.

Strengths and limitations

The strengths of the study include an international prospective cohort with long-term follow-up and standardized methodology of outcome ascertainment. Rigorous metabolic profiling for both the mother and the offspring was conducted. Overall, breastfeeding rates were high in this international cohort.

The limitations of the study include the lack of granularity data on breastfeeding, including breastfeeding duration and exclusivity. These factors are important when evaluating the cumulative effect of breastfeeding on maternal and child long-term cardiometabolic health.^35,43 Additionally, this analysis did not account for social determinants of health nor health-promoting behaviors that could affect breastfeeding and cardiometabolic outcomes, which were not collected in this study. As this was an international study across seven countries, participants likely had variable duration of maternity leave and variable access to paid maternity leave. As maternity leave plays a pivotal role in facilitating breastfeeding initiation and duration, it should be included in future research on long-term breastfeeding effects on cardiovascular health. This cohort also excluded individuals who may be at a higher risk of not breastfeeding as well as at a higher risk of adverse cardiometabolic outcomes, including those with a preterm birth and pregestational diabetes. However, this would likely result in nondifferential misclassification and bias study results to the null.

Conclusion

In conclusion, breastfeeding was associated with lower odds of maternal dyslipidemia and child dysglycemia and adiposity 10–14 years after delivery. These results from a large prospective international cohort emphasize the benefits of breastfeeding toward improving multiple measures of maternal and child cardiovascular health.

Footnotes

Authors’ Contributions

A.P., Y.C., and K.K.V. were responsible for study design, data interpretation, and composing and editing the article. Y.C. performed the analysis. All authors were involved in preparing the article. All authors contributed equally to this work. All authors approved the final article as submitted and agreed to be accountable for all aspects of the work. Each author has indicated that he/she has met the journal’s requirements for authorship. A.P. generated the idea. Y.C. conducted the statistical analysis and wrote the first article draft. A.P. and K.K.V. edited the article draft.

Author Disclosure Statement

No authors have any conflicts of interest to declare, with respect to the research, authorship, and/or publication of this article.

Funding Information

The Hyperglycemia and Adverse Pregnancy Outcome Follow-Up Study (HAPO FUS) was conducted by the HAPO FUS Investigators and supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and the American Diabetes Association. The HAPO study was supported by the National Institute of Child Health and Human Development and the American Diabetes Association. The data from the HAPO FUS reported here were supplied by the NIDDK Central Repository. A.P. is supported by the NICHD grant numbers HD108194 and UHD113408.

Supplementary Material

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Supplementary Material

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Breastfeeding and Maternal and Child Cardiometabolic Outcomes 10–14 Years after Delivery

Abstract

Background:

Objective:

Study Design:

Results:

Conclusions:

Community Brief

A. Why was this study conducted?

B. What are the key findings?

C. What does this study add to what is already known?

Introduction

Methods

Study setting

Participants

Procedures

Exposure

Outcomes

Statistical analysis

Results

Discussion

Principal findings

Results in the context of what is known

What our study adds to what is already known

Clinical and research implications

Strengths and limitations

Conclusion

Footnotes

Authors’ Contributions

Author Disclosure Statement

Funding Information

Supplementary Material

References

Supplementary Material