Running head: INTEGRATIVE REVIEW 1

Integrative Review

Patricia R. Keneagy

Bon Secours Memorial College of Nursing

Arlene Holowaychuk, MSN, RN

NUR 4122

March 27, 2018

“I pledge”
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Abstract

The purpose of this paper is to appraise research literature regarding breastfeeding and the

protective effect it has against childhood obesity. Breastfeeding education plays an important

role in clinical practice, as it effects childbearing families and the health of their children. To

study the relationship between breastfeeding and childhood obesity, a search was conducted

using EBSCO and PubMed, each yielding 48 and 392 articles, respectively. Five articles

published within the last five years were selected based on inclusion criteria determined by the

researcher. Two out of the five articles examined exclusive breastfeeding while the remaining

three investigated breastfeeding regardless of supplemental feedings. The results of these five

articles indicate breastfeeding has a protective effect over childhood obesity. The authors each

determine their own definition of breastfeeding, but all find an inverse relationship between

incidence of breastfeeding and childhood obesity. However, the research has limitations such as

retrospective data and reporter bias. Nonetheless, the relationship between breastfeeding and

childhood obesity is statistically significant. This indicates the importance of education with

childbearing families regarding breastfeeding and its many health benefits. It is recommended

that research continues to better determine the effect of duration of breastfeeding on risk of

childhood obesity.
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Integrative Review

The purpose of this integrative review is to determine if breastfeeding has a protective

effect on childhood obesity in children younger than 17 years of age. It is known that there are

many beneficial effects of breastfeeding on the newborn. Breastfeeding is reported to protect

infants from infectious diseases because it contains defensive components such as enzymes,

antibodies and growth factors from the mother that can combat infection (Grube, von der Lippe,

Schlaud & Brettshneider, 2015). The American Academy of Pediatrics currently suggests six

months of exclusive breastfeeding for best possible health outcomes for the infant (Umer et al.,

2015). Existing research draws a link between breastfeeding and protection against childhood

obesity (Grube et al., 2015). However, some believe this relationship to be overestimated, and

this is the reason this topic continues to be of interest and studied. The information regarding

beneficial effects of breastfeeding is important to clinical practice as it relates to the education of

childbearing parents, and the health of their children. The aim of this integrative review is to

evaluate literature pertaining to the PICOT question, does breastfeeding influence the chance for

childhood obesity in children younger than seventeen years of age?

Design and Search Methods

The search for appropriate research articles was conducted using computer-based search

engines PubMed and EBSCO databases. Search terms utilized included, ‘breastfeeding’,

‘childhood’, ‘obesity’, and ‘overweight.’ The EBSCO search yielded 48 research articles, and

the PubMed search yielded 392 articles, indicating an abundance of research related to the

effects of breastfeeding on childhood obesity. The search was limited to full text, peer-reviewed

qualitative research journal articles, each published in English between the years 2013 and 2018.

The articles had to pertain to the researcher’s PICOT question, does breastfeeding influence the
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chance for childhood obesity in children younger than seventeen years of age? Articles were

selected based on the following inclusion criteria: children younger than seventeen years of age,

breastfeeding defined as a major variable, weight status defined as normal, overweight, or obese,

and body mass index (BMI) defined as a major variable. Articles that did not meet these criteria

were excluded from the review. The screening process involved inclusion criteria and the

relevance to the PICOT question, and yielded five correlational study research articles.

Findings and Results

The findings and results of the five reviewed studies indicate breastfeeding has a

protective effect on childhood overweight and obesity (Assuncao, Ferreira, Coutinho, Santos, &

Horta, 2015; Grube et al., 2015; Rossiter et al., 2015; Umer et al., 2015; Wang, Collins, Ratliff,

Xie. & Wang, 2017). A summary of this compiled research is presented in the appendix. This

integrative review is framed according to the following categories: exclusive breastfeeding and

nonexclusive breastfeeding.

Exclusive Breastfeeding

Two of the qualitative studies included in this review specifically identified exclusive

breastfeeding as a variable (Assuncao et al., 2015; Rossiter et al., 2015). The correlational study

conducted by Assuncao et al. (2015) defined exclusive breastfeeding as the newborn being fed

breastmilk only, without supplementation from water, tea, juice or any other nutrition for at least

six months. The purpose of this study was to specifically identify the relationship between

breastfeeding and the protection against obesity in developing countries. This qualitative study

was performed using data collected by survey and assessment on National Immunization Day in

Brazil.
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Information was collected through parent interviews and anthropometric assessments of

children; both were performed and documented by local health professionals. The initial sample

included 16,934 randomly selected children. The final sample included 2,209 children, aged 12

to 24 months with complete breastfeeding information available. The data collected from these

children and their parents was analyzed using means and standard deviations to produce weight-

for-length z-scores. Additionally, a Student’s t-test was performed to compare means between

groups, and linear regressions were completed to assess the effect of exclusive breastfeeding on

weight-for-length z-scores.

Assuncao et al. (2015) found that the mean weight-for-length z-scores were lower in

children who were exclusively breastfed for at least six months. A total of 38.1% of the 2,209

children included in the sample were exclusively breastfed for greater than or equal to six

months. These children had a lower risk of being overweight as compared to their counterparts

who were exclusively breastfed for less than six months. These results identify a protective

effect of breastfeeding against overweight or obesity as early as the second year of life. This

study contributes to the body of research supporting an inverse relationship between

breastfeeding and obesity.

The purpose of the Rossiter et al. (2015) study was to examine the relationship between

exclusive breastfeeding duration and combination feeding in overweight and obesity in Canadian

school children. This was a correlational study in which the researchers collected retrospective

and present data. The researchers examined breastfeeding duration and the time until formula

was introduced. Rossiter et al. (2015) defined “only breastfed” as breastfeeding longer than six

months without formula, and included those who breastfed longer than one year without formula.
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The researchers used data from the Children’s Lifestyle and School-performance Study II

(CLASS II) survey conducted in 2011 in combination with a Canadian version of the Harvard

Youth Adolescent Food Frequency Questionnaire (YAQ), and height and weight measurements

of consenting students. Additionally, consenting parents were asked to report retrospective data

regarding infant feeding practices. The final sample included 5,560 participants. Data from

these participants was thoroughly analyzed using multilevel regression methods to determine the

association between breastfeeding and overweight and obesity. Additionally, descriptive

statistics were used to characterize the sample by weight status. The association between

breastfeeding duration, combination feeding, and weight status was analyzed using a univariate

regression.

The researchers found children who were only formula fed or combination fed for less

than six months were more likely to be overweight or obese compared to children who were

exclusively breastfed. Fewer children who were breastfed for a longer period of time were

overweight or obese compared to those who were breastfed for a shorter period of time.

Ultimately, the researchers learned that earlier introduction of formula was linked to overweight

and obesity. These results add to the current body of work supporting that breastfeeding has a

protective effect on overweight and obesity, and provides a deeper understanding of combination

feeding variables.

Nonexclusive breastfeeding

The remaining three articles looked at the relationship of breastfeeding and overweight or

obesity without specifying exclusive breastfeeding as a study variable (Wang et al., 2017; Umer

et al., 2015; Grube et al., 2015). The purpose of the study conducted by Wang et al. (2017) was

to examine the effects of breastfeeding and its duration on development of childhood obesity
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from age 24 months through grade six. In this correlational study, data was collected through the

National Institute of Child Health and Human Development Study of Early Child Care and

Youth Development in four phases. Families with children were recruited in the first phase,

lasting from the years 1991 to 1995, when the children were zero to three years old. Data

regarding breastfeeding incidence was used from age one month and six months, and

breastfeeding was dichotomized as breastfeeding or not breastfeeding. Information regarding

supplemental feeding was not collected.

Anthropometric measurements were taken at 24 months, 36 months, 54 months, grade

one, grade three, and grade six. Each child’s body mass index (BMI) was calculated with

collected height and weight measurements. Wang et al. (2017) defined obesity as a BMI greater

than or equal to 95th percentile, and defined overweight as a BMI greater than or equal to the 85th

percentile. The final sample consisted of 545 children with height and weight data collected at

least one time out of six opportunities, and breastfeeding information at one month after birth.

Descriptive analysis was completed to determine breastfeeding status compared to child and

mothers’ characteristics. Chi-square and t-tests were completed to determine the association of

breastfeeding status and weight status. Means, standard deviations and proportions were

calculated to describe childhood overweight and obesity by breastfeeding status at different ages.

Lastly, univariate and multiple logistic regressions were completed to estimate the effects of

breastfeeding at one month on the risk of overweight and obesity as the child aged.

Wang et al. (2017) found that breastfeeding at one month was associated with 53% and

47% decreased risks for obesity at grades one and grades six, respectively. Additionally,

breastfeeding longer than six months duration was associated with a 42% decreased risk. The
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authors conclude that breastfed children appear less likely to be overweight and obese than those

who were not breastfed.

The Umer et al. (2015) study looked at the association between breastfeeding and

childhood obesity in rural Appalachia in West Virginia. This region has one of the highest rates

of childhood obesity, and lowest rates of breastfeeding in the United States. The authors used

two cross-sectional data sets to perform a correlational study. Information was collected using

the West Virginia Birth Score Project and the Coronary Artery Risk Detection in Appalachian

Communities (CARDIAC) Project. The researchers paired Birth Score Project information

collected between the years 1999 and 2002 with data collected by the CARDIAC Project

between the years 2011 and 2012. The child’s identification number was used to create a linked

data set, and only included participant information where data was available from both projects,

yielding a sample of 5,929 participants.

The authors used the collected height and weight information to calculate the body mass

index percentile, and compiled retrospective data pertaining to breastfeeding from the

CARDIAC questionnaire. The authors focused on whether breastfeeding was introduced, not at

exclusive breastfeeding or duration of breastfeeding. Statistical analysis was conducted using

the collected data. A t-test was used to determine statistical significance between BMI percentile

of those breastfed versus those not breastfed. Multiple regression analysis was used to examine

the relationships between variables once the authors controlled for identified covariates. Results

indicated that the mean BMI percentile of West Virginian children who were not breastfed was

20.03%; those who were breastfed had a mean BMI percentile of 16.68%, this 3.4% difference

was determined to be significant.

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Similarly, the purpose of the Grube et al. (2015) study was to examine the relationship

between breastfeeding for longer than four months duration and overweight and obese children

in Germany. While the authors did determine a duration, they were unable to determine

exclusive breastfeeding in their data collection. Grube et al. (2015) believed that the beneficial

effect breastfeeding has on childhood obesity may be overestimated and conducted an

observational study including retrospective data to inspect this relationship.

The authors used data collected through the German Health Interview and Examination

Survey for Children and Adolescents (KiGGS) between the years 2003 and 2006. The sample

was randomly selected from those participating in the study and ultimately yielded 8,034

participants. The survey involved questionnaires to be completed by both parents and their

children, physical examinations including anthropometric measurements, blood, and urine

testing, and a personal interview. The data was analyzed using odds ratios to determine the

association between breastfeeding and overweight and obesity in German children. A logistic

regression analysis was performed to examine stratified age groups and the protective effect

breast feeding had on overweight and obesity. The researchers determined a positive correlation

between breastfeeding longer than four months duration and a decreased incidence of overweight

and obesity in childhood. The age-adjusted analysis of the data showed that the protective effect

was most significant from seven to ten years of age.

Discussion and Implications

Each of the articles included in this integrative review address the relationship between

breastfeeding and childhood obesity. The determined PICOT question was, does breastfeeding

influence the chance for childhood obesity in children younger than seventeen years of age?

Assuncao et al. (2015) and Rossiter et al. (2015) specifically identified exclusive breastfeeding
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as a study variable, while Wang et al. (2017), Umer et al. (2017), and Grube et al. (2015) all

examined breastfeeding incidence regardless of supplemental nutrition in their determination of

the relationship with childhood obesity. Rossiter et al. (2015) found that “breastfeeding, in the

absence of formula feeding, appears to have a protective effect on childhood obesity” (p. 2054).

Despite discrepancy in variables, all five of the articles generated similar conclusions,

supporting that breastfeeding does decrease the risk of childhood obesity. The findings of Grube

et al. (2015) “support the hypothesis that breastfeeding has a protective effect on childhood

overweight and obesity” (p. 14). Similarly, Wang et al. (2017) found that breastfeeding had a

significant effect on childhood obesity, specifically when the child was breastfed for at least six

months. Wang et al. (2017) stated the “lowest prevalence of obesity was found in children who

were breastfed for six months compared to those who were breastfed less than six months or

never breastfed” (p. 203). Umer et al. (2015) examined the protective effect breastfeeding had in

children reaching the fifth grade and noted that their conclusion “adds to the argument of

encouraging breastfeeding as one of the potential preventative measures in reducing childhood

obesity prevalence” (p. 454).

The research supports the need for early education of expecting parents regarding the

importance of breastfeeding. Many health professionals counsel parents on breastfeeding as it

relates to immunity because as noted by Grube et al. (2015), it is understood that “breast milk

contains nutrients, enzymes, hormones, antibodies, and growth factors that assist in combatting

infectious agents” (p. 2). The findings and statistics included in this review indicate that

breastfeeding has a protective effect on childhood obesity and should be encouraged. However,

more research needs to be done concerning specific duration of breastfeeding and combination

feeding. Many studies rely on retrospective data and dichotomize breastfeeding as a “yes” or
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“no” question on a survey. It would behoove the medical community to more closely examine

these time-based variables to provide the best possible information to patients.

Limitations

This integrative review was not without limitations. While the topic of breastfeeding is

widely studied, more research can be done regarding duration of breastfeeding and its

relationship with overweight or obesity in childhood. Additionally, this review was not

exhaustive and only included five articles that were published within the last five years. It

should also be mentioned that this is the first integrative review conducted by this researcher.

Limitations to the research studies include the collection of retrospective data. This could

include some degree of recall bias on the part of the participants. All samples collected were

randomized, and sample sizes were adequate for the types of studies included in this review.

Variables were clearly defined within each research article. It is worth mentioning that

unobserved or unforeseen confounding of variables is possible throughout each study as well.

Conclusion

The findings of this integrative review indicate that breastfeeding does decrease the

chance of childhood obesity in children younger than seventeen years of age, as questioned by

the researcher. While some research supports the implementation of exclusive breastfeeding

(Assuncao et al., 2015; Rossiter et al., 2015), other studies show that breastfeeding of any

duration, regardless of exclusivity, has a protective effect over childhood obesity (Wang et al.,

2017; Umer et al., 2015; Grube et al., 2015). The importance of breastfeeding education should

continue to be impressed upon new and expecting parents, and should include the relationship

with childhood obesity. This integrative review concludes that breastfeeding has a protective

effect on childhood obesity, and the findings are sufficient to evaluate the PICOT question.
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References

Assuncao, M.L., Ferreira, H.S., Coutinho, S.B., Santos, L.M.P., & Horta, B.L. (2015). Protective

effect of breastfeeding against overweight can be detected as early as the second year of

life: A study of children one of the most socially-deprived areas of Brazil. Journal of

Health, Population & Nutrition 33(1), 85-91. Retrieved from

http://web.b.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=8&sid=10ca1478-140f-

4764-a946-884f4a2a46c7%40pdc-v-sessmgr01

Grube, M.M., von der Lippe, E., Schlaud, M.,, & Brettschneider, A. (2015). Does breastfeeding

help to reduce the risk of childhood overweight and obesity? A propensity score analysis

of data from the KiGGS study. Plos ONE, 10(3), 1-16. doi:10.1371/journal.pone.0122534

Rossiter, M., Colapinto, C., Khan, M., McIsaac, J., Williams, P., Kirk, S., & Veugelers, P.

(2015). Breast, formula and combination feeding in relation to childhood obesity in Nova

Scotia, Canada. Maternal & Child Health Journal, 19(9), 2048-2056.

doi:10.1007/s10995-015-1717-y

Umer. A., Hamilton, C., Britton, C.M., Mullett, M.D., John, C., Neal, W., & Lilly, C.L. (2015).

Association between breastfeeding and childhood obesity: Analysis of a linked

longitudinal study of rural Appalachian fifth-grade children. Childhood obesity (11)4,

449-455. doi:10.1089/chi.2015.0026

Wang, L., Collins, C., Ratliff, M., Xie. B., & Wang, Y. (2017). Breastfeeding reduces childhood

obesity risks. Childhood Obesity (13)3, 197-204. doi:10.1089/chi.2016.0210.

INTEGRATIVE REVIEW 13

Table 1 – Research Article Evaluation

Reference Assuncao, M.L., Ferreira, H.S., Coutinho, S.B., Santos, L.M.P., &
Horta, B.L. (2015). Protective effect of breastfeeding against
overweight can be detected as early as the second year of life: A
study of children one of the most socially-deprived areas of Brazil.
Journal of Health, Population & Nutrition 33(1), 85-91.
Background/ Few studies on association between breastfeeding and protection
Problem Statement against obesity in developing countries – aim to investigate
children exposed to exclusive breastfeeding >/=6 mos showed
lower prevalence of overweight in 2nd year of life
Conceptual/Theoretical Protective relationship between breastfeeding and obesity in
Framework children understood, but under studied in developing countries
Design/ Method/  Data collection from National Immunization Day –
Phil. anthropometric measurements taken after immunization,
Underpinnings interview of parents/caregiver
 Correlational study
Sample/Setting/ Ethical  2209 children (aged 12 to 24 months)
Considerations  Study protocol approved by Research Ethics Committee of
National School of Public Health at Fundacaeo Oswaldo Cruz
 Informed consent and agreement of participation collected
Major Variables  Body-wt, length, age, sex combined to build anthropometric
Studied (and indices – expressed as z-scores
their definition),  Stunting – length-for-age z-scores of <-2
if appropriate  Birthweight categorized as low (<2500g), underweight (2500-
2999) normal (3000-3999g) and high (>/=4000g)
 Exclusively breastfed – only breastmilk, no water, tea, juice, or
any other type of food, for >/=6 months
Measurement  Health and Nutrition Day – survey evaluating children living in
Tool/Data semi-arid region of Brazil
Collection Method  Data collected on National Immunization Day, August 20, 2005
Data Analysis  T-test for independent samples to compare means groups
 Linear regressions – assess effect of exc-BF on weight-for-length
z-scores
Findings/  38.1% of 2209 children were exc-BF for >/=6mos – risk of
Discussion overweight was lower among these children than those exc-BF
<6mos
 Mean weight-for-length z-scores lower in children exc-BF for
>/=6 mos
Appraisal/Worth to  Adds to body of research supporting breastfeeding
practice  Protective effect of breastfeeding against overweight as early as
2nd year of life
 Only evaluated breastfeeding at least 6 months, other studies have
shown longer breastfeeding correlates with lower obesity and
overweight incidence into school age and adolescence
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Reference Grube, M.M., von der Lippe, E., Schlaud, M.,, & Brettschneider, A.
(2015). Does breastfeeding help to reduce the risk of childhood
overweight and obesity? A propensity score analysis of data from
the KiGGS study. Plos ONE, 10(3), 1-16.
doi:10.1371/journal.pone.0122534
Background/Problem Studies suggest beneficial effect of breastfeeding on overweight and
Statement obesity. May be overestimated. This study examined relationship
between breastfeeding > 4 months & overweight & obese children
Conceptual/theoretical  Theoretical framework is not explicitly defined by the author.
Framework  Understood framework based on beneficial effect breastfeeding
believed to have on the risk of overweight and obesity in a child.
Design/Method/Phil.  Retrospectively collected data, observational
Underpinnings  Applied propensity score matching & multivariate logistic
regression analysis (estimate effect of breastfeeding on childhood
overweight & obesity)
Sample/Setting/Ethical  Final sample 8034 participants - Germany
Considerations  Adolescents living in Germany surveyed via German Health
Interview and Examination Survey for Children and Adolescents
 Study approved by Charite-Universitatsmedizin Berlin ethics
committee and by Federal Commissioner for Data Protection
Major Variables  Breastfeeding defined as either exclusive breastfeeding or
Studied (and their predominant breastfeeding with additional supply of water or
definition), if other fluids like tea or fruit juices
appropriate  Breastfeeding dichotomized @ 4 mos. (recommendations on
breastfeeding in Germany vary between 4-6 mos)
 Overweight and obesity – overweight=BMI >90th percentile,
obesity=BMI >97th percentile - Per German reference system
developed by Kromeyer-Hauschild et al. (pg 4)
Measurement  Retrospective survey data
Tool/Data Collection  KiGGS baseline study – German Health Interview & Examination
Method Survey for Children and Adolescents
Data Analysis  Analyzed data using odds ratios to determine association between
breastfeeding and overweight/obesity
 Logistic regression analysis – examine stratified age groups and
protective effect of breast feeding
Findings/Discussion  Positive correlation between breastfeeding longer than 4 months
and decreased incidence of overweight/obesity in childhood
Appraisal/Worth to  Findings fit with existing research
practice  Builds support for breastfeeding and adds specificity to link
between breastfeeding and incidence of overweight/obesity in
certain age groups
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Reference Rossiter, M., Colapinto, C., Khan, M., McIsaac, J., Williams, P., Kirk,
S., & Veugelers, P. (2015). Breast, formula and combination feeding in
relation to childhood obesity in Nova Scotia, Canada. Maternal & Child
Health Journal, 19(9), 2048-2056. doi:10.1007/s10995-015-1717-y
Background/ Breastfeeding and relationship to childhood obesity has been studied, but
Problem combination feeding (breastmilk and formula) has not – aim to
Statement investigate relationship between breastfeeding duration, combo feeding
and overweight/obesity in Canadian school children
Conceptual/  Based on research support for relationship between breastfeeding and
theoretical protection against obesity, looking to expand on understanding of role
Framework of formula feeding
Design/ Method/  Correlational study
Phil.  CLASS II reps went to participating schools to administer Canadian
Underpinnings version of the 147-item Harvard Youth Adolescent Food Frequency
Questionnaire (YAQ) – measured ht & wt (grade 5)
 Retrospective data and present data
Sample/Setting/  Consent and parent sociodemographic collected
Ethical  5560 participants in analysis
Considerations  Study procedures approved by The Dalhousie University and
University of Alberta Research Ethics Boards
Major Variables  Infant feeding – categorized using two variables: duration and when
Studied (and introduced. (Never/<1 week, >/=1week to <3 mos, >/=3 mos to <6mos,
their definition), >/=6 mos to <1yr, >/=1 yr, unsure/prefer not to answer)
if appropriate  Exclusive breastfeeding not determined this study – combo fed option
 BMI – standard ht w/o shoes to nearest 0.1 cm, body wt to nearest 0.1
kg – divided wt in kg by ht (meters squared), then categorized using
adult categorizations of overweight (25.0-25.9) and obesity (>/=30)
Measurement  2011 Children’s Lifestyle and School-performance Study II
Tool/Data (CLASSII)- cross sectional, population based – survey
CollectionMethod  Parents asked to report retrospective data on infant feeding habits
Data Analysis  Multilevel regression methods – association between breastfeeding
duration & overweight/obesity
 Descriptive stats (frequencies, percentiles) – characterize population by
weight status
 Linear and logistic mixed models
 Univariate regression – evaluate association between breastfeeding
duration and wt status and combination feeding & wt status
 Odds ratios – separate for normal weight vs obese, normal weight vs
overweight
Findings/  Children only formula fed or combination fed for <6 months were more
Discussion likely to be overweight or obese relative to children who were only
breastfed
 Combination fed for <6 months compared to only breastfed were more
likely to be overweight
 Only formula fed vs only breastfed was more likely to be overweight
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 Lower proportion of children breastfed for a longer time were

overweight or obese compared to children who were breastfed for a
shorter duration of time
 Earlier introduction of formula linked to overweight and obese
 Children breastfed for 6 months to 1 and </=1 year were significantly
less likely to be overweight/obese
Appraisal/Worth  Supports body of research that breastfeeding has a significant protective
to practice effect against overweight and obesity in childhood
 Relationship between combo feeding and overweight/obesity still not
clear
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Reference Umer. A., Hamilton, C., Britton, C.M., Mullett, M.D., John, C.,
Neal, W., & Lilly, C.L. (2015). Association between breastfeeding
and childhood obesity: Analysis of a linked longitudinal study of
rural Appalachian fifth-grade children. Childhood obesity (11)4,
449-455. doi:10.1089/chi.2015.0026
Background/Problem Rural Appalachia has one of highest rates of childhood obesity and
Statement lowest of breastfeeding, aim of study to examine association
between these factors in rural Appalachia in WV
Conceptual/theoretical  Theoretical framework not explicitly outlined
Framework  Study based on CDC and US Department of Health and Human
Services promotion of breastfeeding as an early strategy for
reducing later childhood obesity
Design/ Method/ Phil.  Two cross-sectional data sets
Underpinnings  Correlational study
Sample/Setting/Ethical  5929 subjects, West Virginia
Considerations  Approved by the West Virginia University Institutional Review
Board
Major Variables  BMI%- 100*log BMI/median BMI – measured with SECA Road
Studied (and their Rod stadiometer (height), SECA 840 Personal Digital Scale
definition), if (weight)
appropriate  CDC EpiInfo software used to calculate BMI, ht and wt
percentiles adjusted for age and gender, BMI z-scores determined
based on these percentiles (CDC 2000 growth charts)
 Breastfeeding – yes, no, don’t know (CARDIAC questionnaire)
Measurement  WV Birth Score Project (Jan 1999-October 2002 data) and
Tool/Data Collection Coronary Artery Risk Detection in Appalachian Communities
Method (CARDIAC – data from 5th grade children 2011-2012)
 Linked data based on child’s ID number, only included sets where
data available from both projects
Data Analysis  T-test – determine if there was statistically significant difference
in unadjusted mean BMI% who were breastfed vs not breastfed
 Magnitude of association calculated using Cohen’s d effect size
 Multiple regression analysis – assess adjusted relationships after
controlling for significant covariates
Findings/Discussion  Mean BMI% of WV children who were not breastfed was 20.03%,
those breastfed were 16.68% (determined to be significant
difference 3.4%)
 Study did not find race to be significant factor, WV predominately
white (94%) - Data showed maternal SES plays important role in
mom’s decision and duration to breastfeed
Appraisal/Worth to  Findings consistent with other studies (inverse relationship)
practice  Strength – ability to examine longitudinal data from two cross-
sectional studies
INTEGRATIVE REVIEW 18

Reference Wang, L., Collins, C., Ratliff, M., Xie. B., & Wang, Y. (2017).
Breastfeeding reduces childhood obesity risks. Childhood Obesity (13)3,
197-204. doi:10.1089/chi.2016.0210.
Background/  Examined effects of breastfeeding and its duration on development of
Problem childhood obesity from 24 mos through grade 6
Statement  Assessed breastfeeding practice
Conceptual/  Theoretical framework not explicitly outlined
theoretical  Framework based on held understanding of link between breastfeeding
Framework and decreased risk of childhood obesity
Design/Method/  Correlational study, longitudinal data
Phil. Underpin.  Logistic regression models and generalized estimating equation
Sample/Setting/  545 children with complete info on breastfeeding at 1 and 6 mos,
Ethical throughout the US
Considerations  Approved by Institutional Review Board at East Tennessee State
University - protocol approved by IRB participating universities
Major Variables  Ht – measured with children standing without shoes, feet together, backs
Studied (and against a calibrated seven-foot measuring stick
their definition),  Wt – physician’s two-beam scale, with minimal clothing & recorded
if appropriate twice (nearest 0.25 lb/0.1 kg)
 BMI- weight in kilograms divided by squared height in meters, used to
determine overweight and obese
 Obesity: BMI >/= 95th percentile; Overweight: BMI >/= 85th
 Breastfeeding – information at 1 and 6 mos used – dichotomized intro
breastfeeding and not breastfeeding
Measurement  National Institute of Child Health & Human Development (NICHD)
Tool/Data Study of Early Child Care & Youth Development (SECCYD)
Collection  Restricted analysis to children w/ measured height & weight data at least
Method in one of the six time points of f/u surveys (pg 198), and with info on
their breastfeeding hx at 1 month after birth
 Anthropometric measures taken at 24, 36, 54 mos, grades 1, 3,&6
Data Analysis  Descriptive analysis – breastfeeding status among US children in
comparison to child & mothers’ characteristics
 Chi-square and t tests – association with breastfeeding status
 Means, standard deviations, proportions– describe childhood overweight
and obesity by breastfeeding status at different ages
 Univariate and multiple logistic regressions – estimate effects of
breastfeeding @1 mo. on risk of overweight&obesity as child aged
 Generalized estimating equation method – estimate parameters,
considers all repeated measurements of outcome accounting for
dependency
Findings/  Breastfeeding @ 1 mo. associated w/ 53% and 47% decreased risks for
Discussion obesity @ grades 1 and 6
 Breastfeeding @ 1 mo. decreased risk of obesity by 36% from ages 24
mos-grade 6
 Breastfeeding>6 mos. (v. never) associated w/decreased risk by 42%
INTEGRATIVE REVIEW 19

 Breastfed children appeared to be less likely to be overweight and obese

than those who were not breastfed (p. 199)
Appraisal/Worth  Supports body of evidence of correlation between breastfeeding and
to practice decreased obesity incidence
Further draws link between breastfeeding for at least 6 months and
decreased incidence through grade 6