Weaning Practices And Later Obesity

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Author(s):

	Margherita Caroli
	Independent researcher. Previously, Head of Nutrition Unit, Department of Prevention ASL Brindisi, Italy.
	View Author’s Full Biography

	Andrea Vania
	Independent researcher. Previously, Full Researcher and Aggregate Professor at the Mother-Child and Urologic Sciences Dept. of the Faculty of Pharmacy and Medicine of ‘Sapienza’ Rome University.
	View Author’s Full Biography

In recent years, many studies have correlated nutrition during the first one thousand days of life with the development of non-communicable diseases, and in particular with the development of obesity (1–4). 

This hypothesis therefore radically shifts the goals of dietary recommendations for six-month-old infants from promoting short-term growth within the limits of the reference curves and preventing any nutritional deficiencies, to achieving a state of optimal health in adult life. In this new spirit, infant and early childhood nutrition would play a very important role as a cost-free preventive factor in counteracting the epidemic of paediatric obesity. 

When speaking of the long-term effects of early nutrition, “programming” must be differentiated from “tracking”, even though both phenomena can be traced back to a common root of epigenetic changes. 

Programming is a general process whereby a stimulus or insult at a critical period of development has a lasting or lifelong impact (5). 

A high intake of protein during the first two years of life, leading to an increased production of insulin-like growth factor 1 (IGF-1), is an example of such programming in the development of obesity (6). 

Tracking is a different phenomenon, in which the stimulus does not act during a specific critical period of risk but consists of a dietary pattern starting in infancy, the negative effects of which on a specific disease may be due to repeated exposure. An example of tracking is the way a high salt intake starting during infancy and continuing beyond it may increase blood pressure and lead to hypertension.  

Challenges of researches­­­

Most studies have focused on the role of breastfeeding versus formula feeding (7,8), as well as on early rapid weight gain in favouring the development of obesity (9).

Few studies, however, have focused on the role of complementary feeding (CF) in promoting long-term health or favouring the development of obesity, even though CF represents the main source of calories and nutrients by the end of the first year of life.

One of the most common reasons given as an explanation for the lack of research on the long-term effects of CF is the huge variation among countries in the foods used during the CF period and the great importance of cultural roots in shaping weaning patterns.

However, if nutrients and calories are considered instead of foods, the differences among countries in CF patterns are much reduced.

Research aiming to demonstrate the link between unhealthy complementary feeding (CF) and the development of later obesity faces several challenges, such as the lack of randomised trials in human populations, the long latency period between exposure and health effects, the difficulty of extrapolating the effects of a single nutrient from the rest of the diet, changes in food composition over time, and, last but not least, the limitations of the recall process in retrospective studies (10). Ethical issues and the long duration of observation, which may negatively influence the results, are major limitations to such studies.

Randomised trials on infants are often unethical. As a consequence, most information derives from observational studies or is extrapolated from data obtained either from older children or from experimental studies on animals.

The long interal between the time at which a specific factor begins to influence nutritional status and its long-term effects in adulthood makes the assessment of its contribution a difficult task, since many other confounding factors may intervene. In addition, the longer the period before recall in a retrospective study, the greater the bias.

The evolution in baby food composition is another, but not less important, source of bias: several changes were introduced gradually over time and inconsistently among different companies and across countries, leading to very different compositions. These modifications obviously limit the correct analysis of the long-term effects of baby foods on health outcomes.

Finally, extrapolating the effects of a nutrient from the rest of the diet is a difficult and risky task. When comparing the effects of two isocaloric diets, reducing or increasing the amount of a specific nutrient in a sample will necessarily cause a compensatory change in at least one other nutrient. This new balance makes it difficult to differentiate or isolate the role of that specific nutrient: its effects could be increased or reduced by the influence of other nutrients present in the diet, or the effects could be entirely due to the new nutrient balance.

However, these difficulties should not discourage scientists from conducting further research studies, as similar obstacles were encountered 40 years ago by researchers striving to understand the relationship between early malnutrition and brain development (11). Since obesity has become a true epidemic all over the world, any ethically sound action that may counteract its further spread must be undertaken.

Complementary feeding is thought by many authors to influence the later development of obesity through several mechanisms, including the age at which solid foods are introduced, the excess of calories intake, the excessive or insufficient intake of specific nutrients, the quality of certain nutrients, the development of eating habits, and so on.

Early introduction of solid foods

In the 1980s, the nutrition committees of the AAP and ESPGHAN had already highlighted that the early introduction of solid foods (< 4 months) caused excessive weight gain (12,13). Later on, other observational studies have found that early introduction of solid foods is positively associated with obesity in preschool children (14,15). This is especially true in formula-fed infants (16). However, other studies failed to confirm the association between early introduction of solid foods and the development of obesity during childhood (17–19).

Studies have shown the effects of early introduction of solid foods at different ages. A cohort study did not show a relationship between early introduction of solid foods (< 15 weeks) and children’s weight at 2 years of age (20), but found a correlation at a later age, when children were 7 years old (21).

The study with the longest interval between the introduction of solid foods and the development of obesity was published in 2010. It showed that children born in the late 1950s who introduced solid foods later had a lower BMI at the age of 42 years. No effect related to the age of introduction of complementary feeding (CF) was seen earlier in life (22). These results, however, may have been strongly influenced by the very different composition of baby food during the early 1960s.

Two systematic reviews concluded, more recently, that a clear association between the timing of the introduction of complementary foods and childhood overweight or obesity is lacking (23,24). However, there is some evidence that the very early introduction of CF (at or before 4 months), rather than at 4–6 months or after 6 months, may increase the risk of childhood overweight.

In conclusion, even though the evidence of an association between early introduction of solid foods and obesity at later ages is weak, maintaining a prudent attitude and introducing solid foods around 6 months of age can only enhance potential short- and long-term general health benefits.

Role of nutrients from complementary feeding in promoting obesity development

The role of nutrients in promoting the development of obesity in later ages has to be approached in terms of both quantity and quality. 

The exact composition of human milk is difficult to assess, as it varies over time in a given mother and among different women. In all cases, it differs markedly from formula composition; hence, the effects of complementary foods should be differentiated according to the milk source. Rephrasing this, a lack of differentiation in CF patterns according to the milk source would imply that breastfeeding and formula feeding are interchangeable, which is clearly not true. Official recommendations, however, do not yet advise differentiating the introduction of complementary foods based on whether the infant is breastfed or formula-fed. Nonetheless, the confounding factor represented by human milk versus formula, and their nutritional differences, must be taken into account when trying to analyse the role of nutrients in promoting obesity. 

Proteins

Generally speaking, infants living in developed countries experience a notable increase in protein intake when starting CF. 

The first study showing a correlation between protein intake in infancy and obesity in later life was published around 30 years ago. In this cohort study, a high protein intake at 24 months (>18% of total energy intake) was correlated with an early adiposity rebound (25). Since then, several longitudinal studies have confirmed these results. Scaglioni and co-workers, using a 24-hour recall, showed a correlation between high protein intake at one year (22% vs. 20%) and overweight status at 5 years of age (26). Günther and co-workers, using a sample of children participating in the DONALD study, showed that high protein intake at 12 months and between 18 and 24 months of age was correlated with a higher BMI Z-score and fat mass percentage at 7 years (27). Öhlund and co-workers found that protein intake at 17-18 months and at 4 years were independent contributing factors to a higher BMI at 4 years of age, in a sample of 127 children (28). However, other studies did not confirm these findings. Dorosty and co-workers did not find any correlation between protein intake at 8 and 18 months of age and BMI in a cohort of almost 900 children participating in the ALSPAC study (29). The total sample, however, showed a remarkable homogeneity in protein intake, which was below 17%, lower than the level (>18%) at which an early adiposity rebound seemed to be facilitated, according to Rolland-Cachera (25). 

No correlation was found either by Hoppe and co-workers in 143 children born in 1987-1988, whose energy and protein intakes were accurately measured at nine months of age. BMI and body fat mass were assessed at that same age and again at ten years of age (30). 

However, all the aforementioned studies evaluated the quantitative aspects of protein intake, while the qualitative ones were seldom taken into account. The appropriateness of such an approach is at least questionable. Whereas the functional and qualitative specificities of human milk proteins are frequently cited to explain the protective effects of breastfeeding, the diverse properties, compositions, and functions of the proteins in formulas and baby foods are essentially overlooked. 

Therefore, the controversial results of these different studies may be explained by the use, in the daily diets of infants, of foods with differing protein compositions (milk / meat / vegetables / legumes), especially if given in different proportions, according to actual eating habits in each country. 

This criticism makes particular sense, as the few published studies suggest that high intake of protein solely from milk and dairy products is likely to be associated with increased fat mass at different ages, whereas protein from meat and vegetables does not seem to play a significant role (31–33). The correlation between protein intake and subsequent increase in BMI appears to be mediated by an increase in IGF-1 synthesis (34). 

In summary, high protein intake in infancy – and particularly high intake of dairy protein – seems to be associated with the risk of developing obesity later in life, but further research is needed to better clarify the nature of this association (35). 

Fats

The relationship between fat intake during the CF period and the development of obesity is even more controversial than that with proteins. According to several scientific institutions, fat intake should decrease from 40-60% of total energy intake at 6 months to about 35% at 24 months, and 25-30% after 4 years of age (36,37). 

Data from the STRIP study, launched in 1989 in Finland – where the rate of coronary heart disease mortality is among the highest in the world (38) – affirm that a strong reduction in fat intake (to 25-30% of total daily energy intake, with a correct unsaturated/saturated fat ratio) from 7 months of age onward is protective against cardiovascular diseases, especially in boys, as compared with a control group with no reduction in fat intake (39,40). The two groups did not show any difference in BMI at any age up to 18 years (39). Although interesting, these data originate from a country with a specific epidemiological context. Confirmation by studies conducted in other countries with different epidemiological backgrounds is therefore highly needed. 

As a matter of fact, other studies – mainly conducted by a French group – provide different information. A cohort already studied to evaluate the role of high protein intake in causing an early adiposity rebound was followed up to 20 years of age. A low fat intake at two years of age was found to be associated with increased fat mass, mostly located in the trunk region in adulthood (41). The authors acknowledge some weaknesses in the study, such as the small sample size and a significantly high drop-out rate, both of which could have influenced the final results. In spite of these limitations, they underline that obesity is present in adults from both developed and developing countries. Whereas high protein intake is reported only in young children from developed countries, low fat intake is observed in both settings (42,43). The authors conclude that significant fat restriction in the first two years of life could increase susceptibility to obesity development when the child is exposed to a high-fat diet later in life (44). 

This apparently conflicting information does not allow for a definitive conclusion regarding the role of low or high fat intake in the first two years of life in promoting later obesity. However, common sense would suggest avoiding both excessive and insufficient fat content in the diet during the first three years of life. Following the path already established by nature and culture, and gradually reducing children’s fat intake as advised by the FAO, is likely to be a much safer approach (36). 

Carbohydrates

Little information is available on the role of carbohydrates during the first two years of life in relation to the development of obesity at a later age. 

This scarcity of information is partly due to the wide variety of definitions used to describe carbohydrate intake (complex and simple sugars). Analysing the carbohydrate content of foods using different techniques leads to varying values reported in food composition databases. Last but not least, the number of studies conducted in infants and toddlers is very limited. All these obstacles make it difficult to compare results from different studies. 

Unlike the studies on protein and fat intakes, the limited research on total carbohydrate intake does not reveal any clear positive or negative association with the development of obesity in this age range. Given the very different metabolic behaviour of starch, oligosaccharides and simple sugars, the analysis must address each of these subgroups individually. In fact, most research in this field focuses on fibres and simple sugars (sucrose, glucose, fructose). 

Fibres.

Fibre intake is thought to positively contribute to a healthy nutritional status. An adequate fibre intake during the first year of life has not been scientifically defined, as the evidence to set recommendations for fibre intake is limited in children and almost lacking in infants. However, the EFSA (European Food Safety Authority) considers that a fibre intake of 2 g/MJ is adequate for children after one year of age (45). 

The STRIP Study demonstrated that the average dietary fibre intake in 8-month-old infants was 3.9 g/day in boys and 3.4 g/day in girls. Dietary fibre intake between 8 months and 2 years of age was not associated with weight gain (46). The authors conclude that a relatively high fibre intake neither reduces energy intake in children aged 13 months to 9 years, nor slows down growth rate between 8 months and 9 years of age (47). 

Simple sugars

The association between simple sugars and the development of obesity has been extensively studied. Sugar-sweetened beverages (SSBs), which include fruit juices, sodas, sweet tea, sports and energy drinks, and so on, are the main source of simple sugars. 

Studies aiming to understand the association between SSBs intake and obesity have shown mixed results. Studies with a larger sample size and/or longer follow-up show a stronger association (48–51), whereas cross-sectional studies with a smaller sample size and/or longitudinal studies with shorter follow-up do not find any association (52–54). 

Among the studies that evaluated the association between SSBs intake in infancy and the development of obesity later in life, a study conducted in Germany on 216 children showed that BMI Z-score at 7 years of age was associated with added sugar intake between 1 and 2 years of age (55). A more recent observational longitudinal study on a larger sample (1189 children at the end of the survey) showed that the prevalence of obesity at 6 years of age in children who consumed SSBs during infancy was twice as high as in those who did not consume SSBs (17% vs. 8.6%) (56). The lack of compensation for high SSB intake by a lower energy intake from other food sources is the most likely mechanism by which obesity development is triggered (48). 

In addition, SSBs are often sweetened with fructose, which does not increase insulin levels as much as glucose does; high levels of plasma triglycerides are the consequence of unsuppressed lipolysis (57). Moreover, fructose-sweetened beverages can affect satiety, as fructose has been shown to have a lower satiating power than glucose. Furthermore, fructose-sweetened beverages decrease leptin levels and increase ghrelin levels. Since insulin and leptin—and possibly ghrelin—function as key signals to the central nervous system in the long-term regulation of energy balance, a decrease in circulating insulin and leptin and an increase in ghrelin concentrations caused by high fructose intake may lead to increased caloric intake and ultimately contribute to weight gain and obesity during chronic consumption of high-fructose diets (58). 

SSBs intake during infancy more than doubles the likelihood of consuming SSBs as much or more than once per day at six years of age (59). This link is a good example of how a tracking behaviour can influence health later on. 

In conclusion, SSBs intake in infancy can influence the development of obesity. As there is no reason to offer SSBs to infants, they should not be given at any age, and should be particularly avoided during infancy and early childhood (60). 

Food variety and taste development

The influence of the CF in favouring the development of obesity is not restricted to the effects of nutritional and metabolic factors. During the first year of life, infants shift from consuming only breast milk or formula to discovering a wide range of foods with different flavours, textures, and tastes. Infants tend to prefer sweet and salty tastes and to dislike sour and bitter ones (61-63). These innate preferences may later in life favour the intake of unhealthy foods, since energy-dense, palatable foods rich in fat, sugar, or salt are abundant in our contemporary food environment (64). 

Food preferences, however, can be modified through a process of “food learning” (65,66). This possibility is very important, since early food preferences during the first two years of life may persist for a long time – sometimes even into adulthood (67). 

During the CF period, a poor variety of foods offered, and a monotonous pattern of taste development may be responsible for the formation of eating habits that predispose to unhealthy food preferences or highly selective eating behaviours, which in turn could contribute to the development of obesity. 

Repeated exposure to healthy foods from the beginning of the CF is essential to acquire healthy food preferences. Exposure does not mean visual exposure only, but must include actual tasting (68). At least eight repeated exposures – probably many more – have been shown to be necessary for a new or initially disliked food to be accepted (69,70). 

Conclusion

Many studies confirm that the CF period is a key stage for improving health in both the short and long term. Even though no universal agreement has yet been reached, some recommendations can be stated. 

Timing: offering CFs at 4 months of age may increase the risk of developing obesity, and there is no advantage in introducing CFs before 6 months of life. 

Proteins: high protein intake in infancy, and particularly high dairy protein intake, seems to be associated with a higher risk of developing obesity later in life, although the nature of this relationship is not yet clear. 

Fats: data remain very controversial, and no definitive conclusion can be drawn. Whether reducing fat intake during the first two years of life may help prevent obesity is still unclear. However, a gradual reduction in fat intake from 50% at birth to around 30% by three years of age can be considered a safe approach. 

Fibre: there is no evidence that fibre intake during infancy plays a role in either promoting or preventing obesity. From a general point of view, however, since fibre is mainly present in fruit and vegetables, these should be included in children’s daily diet from infancy. 

Simple sugars: SSBs intake during infancy may favour the development of obesity. As there are no health benefits from SSBs consumption, there is no reason to offer them – especially during infancy and early childhood. 

Food variety and taste development: during the CF period, a strong “food learning” process must take place. Mothers need to understand that food variety is important for developing healthy eating habits, and that at least eight (probably more) repeated exposures to healthy foods from the beginning of the CF period may be necessary for the acceptance of new foods and the acquisition of healthy food preferences. 

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