1. 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

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

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

4. 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

5. Gestational Weight Gain
2009 IOM Recommendations
E-Moms
Background
Design
Results
Weight Change
Results
Conclusions
Eating Behavior
Background
Design
Results
Conclusions
Future Directions

6. 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

7. 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:

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

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

16. 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

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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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.

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

25. 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

26. 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

27. 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

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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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.

40. 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