Maternal eating behavior in low income mothers influences attitudes towards infant feeding Abby D. Altazan M.S. Research Specialist Reproductive Endocrinology & Women’s Health Pennington Biomedical Research Center Baton Rouge, LA

Reproductive Endocrinology & Women’s Health Pennington Biomedical Research Center Baton Rouge, LA

Outline E-Moms Study Eating Behavior Background Design Participant Characteristics Weight Change Results Future Directions Conclusions

At the end of this session, you will be able to: Identify maternal eating behaviors and attitudes that affect maternal attitudes toward infant feeding Determine the differences in infant feeding attitudes between mothers who were breastfeeding and mothers who were formula feeding

Gestational Weight Gain 2009 IOM Recommendations E-Moms Background Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Future Directions http://www.iom.edu/About-IOM/Making-a-Difference/Kellogg/HealthyPregnancy.aspx

Excess Gestational Weight Gain More pronounced in women with overweight and obesity E-Moms Background Background Design Design Results Results Weight Change Weight Change Results Results Conclusions Conclusions Eating Behavior Background Design Results Conclusions Future Directions Source: CDC PNSS Report, 2011

Postpartum Weight Retention Meta-analysis across 9 studies (>65,000 women) E-Moms Background Design Results Weight Change Results Conclusions Eating Behavior 5 kg 20 kg HEAVIER After 20 years Background Design Results Conclusions Future Directions Nehring I et al. Am J Clin Nutr 2011; 94: 1225-1231

It’s a Cycle! GWG retained Increased BMI Pregnancy Weight gained E-Moms Background Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Future Directions

SmartLoss App E-Moms Background Design Results Weight Change Results Conclusions Eating Behavior Subject data are entered into a web portal which runs data through equations creating calorie targets and the weight graph Output are loaded via the app onto the subject’s SmartPhone. A clinician dashboard summarizes and displays data, runs reports, etc. for counselors (treatment delivery). Meal planning Portion control Label reading Specific nutrients Portion controlled foods Choose My Plate Eating on a budget Use of WIC package Building a good support system Mindful eating Snacking and hunger control Behavior chains Relaxation Background Design Results Conclusions Future Directions

E-Moms Study E-Moms A Personalized Telehealth Intervention for Health and Weight Loss in Postpartum Women Background Design Results To test the efficacy of a 4 month smartphone-based healthy lifestyle intervention to: Promote weight loss Reduce postpartum weight retention Improve diet quality Weight Change Results Conclusions Eating Behavior 10% weight loss in 16 weeks Background Design Results Conclusions Future Directions

Population Postpartum (up to 8 weeks) Receiving WIC Services E-Moms Postpartum (up to 8 weeks) Receiving WIC Services >18 years of age English speaking Background Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Future Directions

Design Prospective, parallel arm, randomized control trial WIC Moms: E-Moms Prospective, parallel arm, randomized control trial Background Design Results WIC Moms: Traditional WIC nutritional counseling WIC E-Moms: + SmartPhone Intervention Weight Change n=20 Results Study Outcomes: Baseline +2 months +4 months Conclusions 40 women Eating Behavior Background Design Results Conclusions Future Directions

Visit Schedule Assessment Screening Baseline 2 months 4 months E-Moms <2m postpartum Baseline 2m postpartum 2 months 4m postpartum 4 months 6m postpartum Weight X Vital signs Circumferences Body Composition (BIA) AE and C-meds Food intake (RFPM) Accelerometry (Actigraph) Demographics and Family Questionnaire Maternal Eating Behavior (Eating Inventory) Maternal Attitudes on Infant Feeding (Infant Feeding Styles Questionnaire) Background Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Future Directions

WIC Clinics E-Moms Study was integrated into clinic flow 1 day per week at WIC clinics All study visits could be completed at the WIC clinics Study equipment was provided to the participants $50 Walmart gift card was provided for completion of each study assessment visit ($150 total) Background Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Future Directions

Consort-Throughput E-Moms Background Design Results Weight Change Conclusions Eating Behavior Maybe remove Background Design Results Conclusions Future Directions

Baseline Characteristics E-Moms WIC Moms (Control) WIC E-Moms (Intervention) p value Age (y) 27 ± 5.9 26 ± 5.1 0.5 Weight (kg) 88.4 ± 9.8 83.8 ± 13.5 0.3 Enrollment BMI (kg/m2) 32.7 ± 2.8 31.3 ± 3.2 0.2 Body Fat (%) 41.7 ± 3.8 40.2 ± 4.7 Parity 2 ± 1.7 1.6 ± 1 0.4 Race White Black Asian 2 14 6 12 1 Education Some High School High School/GED 1-3 Years College College Degree Post Graduate 3 9 5 Background Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Future Directions

What was the effectiveness of the WIC E-Moms intervention on body weight?

Weight Change from Baseline E-Moms WIC Moms (Control) WIC E-Moms (Intervention) p value Weight change (kg) 1.8 ± 0.9 -0.1 ± 0.9 0.1 Background Design Results Weight Change Results Conclusions WIC Moms WIC E-Moms Eating Behavior Weight change is variable and individual Background Design Results Conclusions Future Directions

Increased counselor contact Participant #1 Profile Participant Profile Age 25 Height 66 in Weight 199 lb Enrollment BMI 32.1 kg/m2 E-Moms Background Increased counselor contact Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Future Directions

Decreased participant engagement Participant #2 Profile Participant Profile Age 28 Height 62 in Weight 181 lb Enrollment BMI 33.1 kg/m2 E-Moms Decreased participant engagement Background Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Future Directions

Intervention Adherence E-Moms Assessment Days Completed Days Expected Adherence Weight 80 110 73% Step Count 90 82% Average 77% Background Design Results Weight Change Results Adherence is defined as: 100 × Days weighed Days between + Step counter worn Days between 2 Conclusions Eating Behavior Background High adherence: >70% (days/week = 5) Medium adherence: 40-70% Low adherence: <40% Design Results Conclusions Future Directions

Weight Change By Adherence E-Moms Background Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Different superscripts (a,b) denote significant (p<0.05) between group differences. Future Directions

What was the effectiveness of the WIC E-Moms intervention on body weight and body composition? Postpartum body weight change is highly variable in women receiving WIC benefits (-8.7 to 10.8 kg). eHealth interventions can facilitate weight loss in postpartum women receiving WIC benefits when adherence is >70%. Overcoming barriers unique to the WIC population should be incorporated into future interventions.

What is the relationship between maternal eating behavior and maternal attitudes toward infant feeding?

Infant Feeding E-Moms Individual eating behavior is established early in life. Infants are dependent on caregivers for establishing eating behaviors. Rapid weight gain in infancy is a strong predictor of later obesity. Background Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Future Directions

Infant Feeding E-Moms Background Design Results Weight Change Results Conclusions Eating Behavior Infants who are bottle fed gain more weight across the first year of life as compared to infants fed directly from the breast. Breastfeeding has been shown to reduce the risk of developing obesity later in life but the mechanisms are not well understood. One mechanism that plays a role in weight gain in infancy is caregiver feeding behaviors and beliefs towards feeding. The act of bottle feeding may facilitate a pressuring feeding style as opposed to responsive feeding style. Background Design Results Infants who are bottle fed gain more weight across the first year of life as compared to infants fed directly from the breast. Conclusions Future Directions

Infant Feeding Genes Maternal Obesity E-Moms Infant weight gain and obesity risk Genes Breastfeeding vs Bottle feeding Self-Regulation Breast milk vs Formula Maternal Obesity Gut microbiome Caregiver feeding attitudes and behaviors Background Design Results Weight Change Results Conclusions Eating Behavior Infants who are bottle fed gain more weight across the first year of life as compared to infants fed directly from the breast. Breastfeeding has been shown to reduce the risk of developing obesity later in life but the mechanisms are not well understood. One mechanism that plays a role in weight gain in infancy is caregiver feeding behaviors and beliefs towards feeding. The act of bottle feeding may facilitate a pressuring feeding style as opposed to responsive feeding style. Background Design Results Conclusions Future Directions

Caregiver Feeding Behaviors E-Moms Background Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Future Directions

Caregiver Feeding Behaviors E-Moms Previous studies show that lower maternal responsiveness and awareness to infant cues lead to infants with greater weight gain. Distracted feeding is also a common caregiver practice regardless of mode of feeding. Maternal pressuring may also inhibit infants’ abilities to self-regulate feeding. It is possible that caregivers who engage in mindless feeding themselves may be less aware of their infants’ cues and therefore at higher risk for overfeeding and rapid weight gain. Background Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Future Directions

Eating Behavior E-Moms Aims To compare maternal eating behavior between breastfeeding and formula feeding mothers. To understand the relationship of maternal eating behavior with maternal attitudes toward infant feeding. Background Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Future Directions

Data Collection 35 of the 40 women enrolled in the E-Moms study Cross-sectional baseline analysis at 8 weeks postpartum Questionnaires Feeding Mode Maternal Eating Behavior by the Eating Inventory Maternal Attitudes on Infant Feeding by the Infant Feeding Styles Questionnaire Background Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Future Directions

Eating Inventory E-Moms Evaluates eating behavior in three factor domains: dietary restraint, disinhibition, and perceived hunger. Lower scores for dietary restraint, and higher scores for disinhibition and perceived hunger, indicate less control over eating behavior and more episodic overeating. Background Design Results Weight Change Results Conclusions   Range High Values Indicative of Cognitive Restraint 0-21 Greater Control Disinhibition 0-16 Less Control Hunger 0-14 Eating Behavior Background Design Results Conclusions Future Directions

Infant Feeding Styles Adapted 16 question tool using Likert scale scoring Included 4 subscales (Restrictive feeding, Pressuring/Overfeeding, Responsive feeding, and Beliefs in Benefits of Breastfeeding) Restrictive feeding High score = beliefs that may promote restrictive feeding Scoring range: 3-15 Pressuring/overfeeding High score = beliefs that may promote pressuring/overfeeding Scoring range: 7-35 Responsive feeding High score = beliefs that may promote responsive feeding Scoring Range: 1-5 E-Moms Background Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Adapted from Thompson et al 2009 Future Directions

Infant Feeding Styles Pressuring/overfeeding Responsive feeding E-Moms Background Design Pressuring/overfeeding Results Responsive feeding Weight Change Results Restrictive feeding Conclusions Eating Behavior Background Design Results Conclusions Adapted from Thompson et al 2009 Future Directions

Breastfeeding Moms (n=12) Formula Feeding Moms (n=23) Feeding Mode E-Moms Breastfeeding Moms (n=12) Formula Feeding Moms (n=23) p value Age (y) 29.3 ± 7.0 25.0 ± 3.8 0.06 Enrollment BMI (kg/m2) 31.0 ± 3.3 32.5 ± 2.9 0.2 Race White Black Asian 4 7 1 19 Eating Inventory Disinhibition Perceived Hunger Dietary Restraint 6.0 ± 2.5 4.6 ± 3.2 9.7 ± 3.9 4.7 ± 3.1 4.7 ± 3.3 8.9 ± 3.8 0.9 0.6 Infant Feeding Styles Restrictive Feeding Pressuring Responsive Feeding 3.6 ± 0.7 2.3 ± 0.8 2.6 ± 1.4 4.0 ± 0.8 2.2 ± 0.7 3.0 ± 1.6 0.4 Background Design Results Weight Change Results Conclusions Eating Behavior Breastfeeding: 12 (34%) Formula feeding 23 (66%) African American 26 (74%) Background Design Results Conclusions Future Directions

All Mothers E-Moms Regardless of infant feeding mode, maternal dietary restraint negatively correlated with responsive infant feeding attitudes. Background Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Future Directions

Breastfeeding Mothers E-Moms Higher maternal disinhibition was associated with lower restrictive infant feeding attitudes (p<0.05) and maternal dietary restraint positively correlated with pressuring/overfeeding infant feeding attitudes (p=0.05). Background Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Future Directions

Formula Feeding Mothers E-Moms Higher maternal disinhibition and perceived maternal hunger were significantly correlated with higher restrictive infant feeding attitudes (p<0.01 for both). Background Design Results Weight Change Results Conclusions Eating Behavior Background Design Results Conclusions Future Directions

What is the relationship between maternal eating behavior and maternal attitudes toward infant feeding? Maternal eating behavior influenced infant feeding attitudes. Targeting maternal eating behavior may lead to healthier feeding practices in infants and be useful in the prevention of childhood obesity for families enrolled in WIC.

Acknowledgements Coauthors Anne Gilmore Robbie Beyl Leanne Redman Other E-moms Staff Candice Myers Monica Klempel-Donchenko Porsha Vallo WIC in East Baton Rouge Parish, Louisiana