Feeding Patterns and Weight Among First Nations Children

Examining the Role of Interpersonal Violence in Racial Disparities in Breastfeeding in North Dakota (ND PRAMS 2017-2019)

BACKGROUND

The 2019 overall breastfeeding initiation rate in the US was 84.1%, yet only 76.6% of American Indian (AI) women initiated breastfeeding. In North Dakota (ND), AI women have greater exposure to interpersonal violence than other racial/ethnic groups. Stress associated with interpersonal violence may interfere with processes important to breastfeeding. We explored whether interpersonal violence partially explains racial/ethnic disparities in breastfeeding in ND.

METHODS

Data for 2161 women were drawn from the 2017-2019 ND Pregnancy Risk Assessment Monitoring System. Breastfeeding questions in PRAMS have been tested among diverse populations. Breastfeeding initiation was self-report to "Did you ever breastfeed or pump breast milk to feed your new baby, even for a short period?" (yes/no). Breastfeeding duration (2 months; 6 months) was self-reported how many weeks or months of breastmilk feeding. Interpersonal violence for both 12 months before and during pregnancy based on self-report (yes/no) of violence from a husband/partner, family member, someone else, or ex-husband/partner. An "Any violence" variable was created if participants reported "yes" to any violence. Logistic regression models estimated crude and adjusted odds ratios (OR) and 95% confidence intervals (95% CI) for breastfeeding outcomes among AI and Other Race women compared to White women. Sequential models were adjusted for interpersonal violence (husband/partner, family member, someone else, ex-husband/partner, or any).

RESULTS

AI women had 45% reduced odds of initiating breastfeeding (OR: 0.55, 95% CI: 0.36, 0.82) compared to white women. Including interpersonal violence during pregnancy did not change results. Similar patterns were observed for all breastfeeding outcomes and all interpersonal violence exposures.

DISCUSSION

Interpersonal violence does not explain the disparity in breastfeeding in ND. Considering cultural ties to the tradition of breastfeeding and the role of colonization may provide a better understanding of breastfeeding among AI populations.

Effectiveness of interventions to optimise dietary intakes in the first 1000 d of life in Indigenous children: a systematic review

Objective:

Indigenous infants are disproportionately more likely to have negative outcomes compared to non-Indigenous infants with suboptimal nutrition in the first 1000 d playing a major role. This review aimed to systematically assess the effectiveness of interventions designed to optimise dietary intake and/or nutrition-related behaviours among Indigenous infants globally and to identify whether Indigenous populations were involved in the co-design of the intervention.

Design:

Articles published before June 2020 that reported nutrition-related interventions and outcomes for Indigenous infants were identified from a database search. Data extracted included study aims and design, target population, geographical location, the health condition of the participants, intervention characteristics and outcomes. A narrative synthesis consisting of effects and acceptability of the interventions and involvement of participants in the study design were highlighted.

Settings:

Population-based intervention studies that focused on improving dietary intakes and/or nutrition-related behaviours of Indigenous infants in the first 1000 d of life were included in this review.

Results:

Of the 2784 studies identified, three studies met the inclusion criteria. These were conducted among two Indigenous tribes in Guatemala and the USA. Two studies reported the food and nutrient intake of participants with one study showing an improvement in dietary intake of the infants. Only one study reported community participation in the study design, intervention design and implementation, and acceptability of the intervention by the participants.

Conclusion:

Engaging Indigenous communities throughout the entire process of nutrition interventions could have beneficial effects through improved outcomes in the first 1000 d of life.

Protocol for a scoping review of the qualitative literature on Indigenous infant feeding experiences

INTRODUCTION

Prudent infant nutrition, including exclusive breastfeeding to 6 months, is essential for optimal short-term and long-term health. Quantitative research to date has documented that many Indigenous communities have lower breastfeeding rates than the general population and that this gap in breastfeeding initiation and maintenance may have an important impact on chronic disease risk later in life. However, there are critical knowledge gaps in the literature regarding factors that influence infant feeding decisions. Qualitative research on infant feeding experiences provides a broader understanding of the challenges that Indigenous caregivers encounter, and insights provided by this approach are essential to identify research gaps, community engagement strategies, and programme and policy development. The objective of this review is to summarise the qualitative literature that describes breastfeeding and other infant feeding experiences of Indigenous caregivers.

METHODS AND ANALYSIS

This scoping review will follow guidelines from Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, the Joanna Briggs Institute and the methodological framework from Arksey and O'Malley. In October 2020, we will conduct an electronic database search using Medline, Embase, The Cumulative Index to Nursing & Allied Health Literature (CINAHL), PsycINFO, and Scopus, and will focus on qualitative studies. Publications that have a focus on infant feeding in Canada, the USA, Australia and New Zealand, and the Indigenous caregiver experience from the caregiver perspective, will be included. We will conduct a grey literature search using Indigenous Studies Portal, country-specific browser searches, and known government, association, and community websites/reports. We will map themes and concepts of the publications, including study results and methodologies, to identify research gaps, future directions, challenges and best practices in this topic area.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review as no unpublished primary data will be included. The results of this review will be shared through peer-reviewed publications and conference presentations. This protocol is registered through the Open Science Framework (osf.io/4su79).

Timing of introduction of complementary foods and beverages and growth, size, and body composition: a systematic review

BACKGROUND

The systematic review described in this article was conducted as part of the USDA and Department of Health and Human Services Pregnancy and Birth to 24 Months Project.

OBJECTIVES

The aim was to describe the relationship between timing of introduction of complementary foods and beverages (CFBs) and growth, size, and body-composition outcomes across the life span.

METHODS

The literature was searched and selected using predetermined criteria. Data were extracted and risk of bias assessed for each included study. Evidence was qualitatively synthesized, conclusion statements were developed, and the strength of the evidence was graded.

RESULTS

Eighty-one articles were included in this systematic review that addressed timing of CFB introduction relative to growth, size, and body-composition outcomes from infancy through adulthood. Moderate evidence suggests that introduction of CFBs between the ages of 4 and 5 mo compared with ∼6 mo is not associated with weight status, body composition, body circumferences, weight, or length among generally healthy, full-term infants. Limited evidence suggests that introduction of CFBs before age 4 mo may be associated with higher odds of overweight/obesity. Insufficient evidence exists regarding introduction at age ≥7 mo.

CONCLUSIONS

Although several conclusions were drawn in this systematic review, additional research is needed to address gaps and limitations in the evidence on timing of introduction of CFBs and growth, size, and body composition, such as randomized controlled trials that examine multiple outcomes and/or CFB introduction between the ages of 4 and 6 mo, and research that accounts for potential confounders such as feeding practices and baseline growth status and considers issues of reverse causality.

Prevalence of overweight and obesity among indigenous populations in Canada: A systematic review and meta-analysis

Previous studies on overweight and obesity among indigenous peoples in Canada have been inconclusive. A systematic review was conducted on the prevalence of overweight and obesity among Canadian indigenous populations. Major bibliographic databases were searched for relevant studies published between January 1990 and June 2013. We reviewed 594 abstracts and included 41 studies in the meta-analyses. Using the heterogeneity test (Cochrane Q) results, the overall prevalence was estimated using fixed- or random-effects model. Nonadults (<18 years) had a pooled prevalence of overweight and obesity at 29.8% (95% CI: 25.2-34.4) and 26.5% (95% CI: 21.8-31.3), respectively. The pooled prevalence of overweight and obesity among adults were 29.7% (95% CI: 28.2-31.2) and 36.6% (95% CI: 32.9-40.2), respectively. Adult males had higher overweight prevalence than females (34.6% vs. 26.6%), but lower obesity prevalence (31.6% vs. 40.6%). Nonadult girls had higher prevalence than boys [overweight: 27.6%; 95% CI: 22.6-32.7 vs. 24.7%; 95% CI: 19.0-30.5; obesity: 28.6%; 95% CI: 20.3-36.9 vs. 25.1%; 95% CI: 13.8-36.4]. Nonadult Inuit had the highest overweight and lowest obesity prevalence. Although Inuit adult had the lowest prevalence of overweight (28.7%; 95% CI: 27.3-30.2) and obesity (32.3%; 95% CI: 25.5-39.1), it was relatively high. This study highlights the need for nutritional intervention programs for obesity prevention among indigenous populations in Canada.

Creating exclusive breastfeeding knowledge translation tools with First Nations mothers in Northwest Territories, Canada

Background

Breastfeeding is an ideal method of infant feeding affecting lifelong health, and yet the uptake of breastfeeding in some Indigenous communities in Canada's north is low.

Objective

The aims of this project were to determine the rate and determinants of exclusive breastfeeding in a remote community in the Northwest Territories and to create knowledge translation tools to enhance breastfeeding locally.

Methods

The study methodology followed three steps. Firstly, a series of retrospective chart audits were conducted from hospital birth records of Tłı̨chǫ women (n=198) who gave birth during the period of 1 January 2010 to 31 December 2012. A second follow-up chart audit determined the rate of exclusive breastfeeding and was conducted in the local Community Health Centre. Chart audit data included the following factors related to breastfeeding: age of mother, parity, birthweight and Apgar scores. Secondly, semi-structured interviews with a purposive sample of Tłı̨chǫ mothers (n=8) and one Elder were conducted to identify breastfeeding practices, beliefs and the most appropriate medium to use to deliver health messages in Tłı̨chǫ. Third, based on the information obtained in Step 2, two knowledge translation tools were developed in collaboration with a local community Advisory Committee.

Results

The rate of exclusive breastfeeding initiation in the Tłı̨chǫ region is less than 30%. Physiological and demographic factors related to breastfeeding were identified. Thematic analysis revealed two overarching themes from the data, namely, “the pull to formula” (lifestyle preferences, drug and alcohol use, supplementation practices and limited role models) and “the pull to breast feeding” (traditional feeding method, spiritual practice and increased bonding with infant).

Conclusion

There are a myriad of influences on breastfeeding for women living in remote locations. Ultimately, society informs the choice of infant feeding for the new mother, since mothers’ feeding choices are based on contextual realities and circumstances in their lives that are out of their control. As health care providers, it is imperative that we recognize the realities of women's lives and the overlapping social determinants of health that may limit a mother's ability or choice to breastfeed. Further health promotion efforts, grounded in community-based research and a social determinants framework, are needed to improve prenatal and postnatal care of Indigenous women and children in Canada.

Age at Weaning and Infant Growth: Primary Analysis and Systematic Review

OBJECTIVE

To test whether earlier age at weaning (age 3-6 months) may promote faster growth during infancy.

STUDY DESIGN

Weaning at age 3.0-7.0 months was reported by 571 mothers of term singletons in a prospective birth cohort study conducted in Cambridge, UK. Infant weight and length were measured at birth and at age 3 months and 12 months. Anthropometric values were transformed into age- and sex-adjusted z-scores. Three linear regression models were performed, including adjustment for confounders in a stepwise manner. Measurements at age 3 months, before weaning, were used to consider reverse causality.

RESULTS

Almost three-quarters (72.9%) of infants were weaned before age 6 months. Age at weaning of 3.0-7.0 months was inversely associated with weight and length (but not with body mass index) at 12 months (both P ≤ .01, adjusted for maternal and demographic factors). These associations were attenuated after adjustment for type of milk feeding and weight or length at age 3 months (before weaning). Rapid weight gain between 0 and 3 months predicted subsequent earlier age at weaning (P = .01). Our systematic review identified 2 trials, both reporting null effects of age at weaning on growth, and 15 observational studies, with 10 reporting an inverse association between age at weaning and infant growth and 4 reporting evidence of reverse causality.

CONCLUSION

In high-income countries, weaning between 3 and 6 months appears to have a neutral effect on infant growth. Inverse associations are likely related to reverse causality.

The timing of solid introduction in an 'obesogenic' environment: a narrative review of the evidence and methodological issues

OBJECTIVE

To evaluate the evidence for association between obesity risk outcomes >12 months of age and timing of solid introduction in healthy term infants in developed countries, the large majority of whom are not exclusively breastfed to six months of age.

METHODS

Studies included were published 1990 to March 2013.

RESULTS

Twenty-six papers with weight status or obesity prevalence outcomes were identified. Studies were predominantly cohort design, most with important methodological limitations. Ten studies reported a positive association. Of these, only two were large, good-quality studies and both examined the outcome of early (<4 months) introduction of solids. None of the four good-quality studies that directly evaluated current guidelines provided evidence of any clinically relevant protective effect of solid introduction from 4-5 versus ≥6 months of age.

CONCLUSION

The introduction of solids prior to 4 months of age may result in increased risk of childhood obesity but there is little evidence of adverse weight status outcomes associated with introducing solids at 4-6 rather than at six months.

IMPLICATIONS

More and better quality evidence is required to inform guidelines on the 'when, what and how' of complementary feeding.

Timing of the introduction of complementary feeding and risk of childhood obesity: a systematic review

The World Health Organisation recommends exclusive breastfeeding until 6 months of age and continued breastfeeding until 2 years of age or beyond. Appropriate complementary foods should be introduced in a timely fashion, beginning when the infant is 6 months old. In developing countries, early or inappropriate complementary feeding may lead to malnutrition and poor growth, but in countries such as the United Kingdom and United States of America, where obesity is a greater public health concern than malnutrition, the relationship to growth is unclear. We conducted a systematic review of the literature that investigated the relationship between the timing of the introduction of complementary feeding and overweight or obesity during childhood. Electronic databases were searched from inception until 30 September 2012 using specified keywords. Following the application of strict inclusion/exclusion criteria, 23 studies were identified and reviewed by two independent reviewers. Data were extracted and aspects of quality were assessed using an adapted Newcastle-Ottawa scale. Twenty-one of the studies considered the relationship between the time at which complementary foods were introduced and childhood body mass index (BMI), of which five found that introducing complementary foods at <3 months (two studies), 4 months (2 studies) or 20 weeks (one study) was associated with a higher BMI in childhood. Seven of the studies considered the association between complementary feeding and body composition but only one study reported an increase in the percentage of body fat among children given complementary foods before 15 weeks of age. We conclude that there is no clear association between the timing of the introduction of complementary foods and childhood overweight or obesity, but some evidence suggests that very early introduction (at or before 4 months), rather than at 4-6 months or >6 months, may increase the risk of childhood overweight.

Traditional food consumption behaviour and concern with environmental contaminants among Cree schoolchildren of the Mushkegowuk territory

Objectives

To investigate factors influencing consumption of traditional foods (e.g. wild game, fish) and concerns about environmental contaminants among schoolchildren of the Mushkegowuk Territory First Nations (Moose Factory, Fort Albany, Kashechewan, Attawapiskat, and Peawanuck).

Study design

Cross-sectional data collection from a Web-based Eating Behaviour Questionnaire (WEB-Q).

Methods

Schoolchildren in grades 6–12 (n =262) responded to 4 of the WEB-Q questions: (a) Do you eat game? (b) How often do you eat game? (c) How concerned are you about the environmental contaminants in the wild game and fish that you eat? (d) I would eat more game if… [6 response options]. Data were collected in 2004 (Fort Albany), 2005 (Peawanuck), 2006 (Attawapiskat), 2007 (Moose Factory) and 2009 (Kashechewan). Hierarchical log-linear modelling (LLM) was used for analyses of multi-way frequency data.

Results

Of the schoolchildren answering the specific questions: 174 consumed game; 95 reported concerns about contaminants in game; and 84 would increase their game consumption if it were more available in their homes. LLM revealed significant differences between communities; schoolchildren in Moose Factory consumed game “rarely or never” at greater than expected frequency, and fewer than expected consumed game “at least once a day”. Schoolchildren in Kashechewan had greater frequency of daily game consumption and few were concerned about contaminants in game. Using LLM, we found that sex was an insignificant variable and did not affect game consumption frequency or environmental contaminant concern.

Conclusion

The consumption of traditional foods differed between communities and appears to be related to contamination concerns. In addition, latitudinal variation appears to influence the frequency of traditional food consumption in children; children in the most southerly location consumed traditional food less frequently.

A socioecological framework to understand weight-related issues in Aboriginal children in Canada

Obesity prevention efforts in Aboriginal (First Nations, Métis, or Inuit) communities in Canada should focus predominantly on children given their demographic significance and the accelerated time course of occurrence of type 2 diabetes mellitus in the Aboriginal population. A socioecological model to address childhood obesity in Aboriginal populations would focus on the numerous environments at different times in childhood that influence weight status, including prenatal, sociocultural, family, and community environments. Importantly, for Aboriginal children, obesity interventions need to also be situated within the context of a history of colonization and inequities in the social determinants of health. This review therefore advocates for the inclusion of a historical perspective and a life-course approach to obesity prevention in Aboriginal children in addition to developing interventions around the socioecological framework. We emphasize that childhood obesity prevention efforts should focus on promoting maternal health behaviours before and during pregnancy, and on breastfeeding and good infant and child nutrition in the postpartum and early childhood development periods. Ameliorating food insecurity by focusing on improving the sociodemographic risk factors for it, such as increasing income and educational attainment, are essential. More research is required to understand and measure obesogenic Aboriginal environments, to examine how altering specific environments modifies the foods that children eat and the activities that they do, and to examine how restoring and rebuilding cultural continuity in Aboriginal communities modifies the many determinants of obesity. This research needs to be done with the full participation of Aboriginal communities as partners in the research.

Association between timing of introducing solid foods and obesity in infancy and childhood: a systematic review

Determining early-life risk factors for obesity in later life is essential in order to effectively target preventative interventions to reduce obesity. The aim of this systematic review was to investigate current evidence to determine whether the timing of introducing solid foods is associated with obesity in infancy and childhood. Relevant randomized and observational studies from developed countries were identified by searching the following six bio-medical databases (Medline, Embase, British Nursing Index, CINAHL, Maternity and Infant Care, and PsycINFO) and hand-searching reference lists. Studies of pre-term or low birthweight infants were excluded. Twenty-four studies met the inclusion criteria for the systematic review. Data from over 34,000 participants were available for interpretative analysis. No clear association between the age of introduction of solid foods and obesity was found. It is likely that a whole family approach to obesity prevention will be most effective and health professionals should continue to promote healthy infant feeding in line with national recommendations.

Transformation to Room Service Food Delivery In a Pediatric Health Care Facility

Patient food service is an important component in the nutritional management of hospitalized children. The previous meal delivery system at The Hospital for Sick Children in Toronto was a cold-plating re-thermalized system. Issues related to this model included order lead time, the reheating process, menu selection, and service style. Research into other systems led us toward room service, an innovative and flexible mode of meal delivery. Transformation to room service occurred over one year, and included implementation of a new computer system, kitchen renovation, redesign of menus and a new meal delivery system called Meal Train, and changes to human resource allocations. Throughout the transformation, consultations were held with key stakeholders, including the children’s council, the family advisory, the nursing council, and a multidisciplinary committee involving nursing staff, dietitians, patient service aides, infection control personnel, occupational health employees, patient representatives, and food services staff. Now, Meal Train is running smoothly, and meal days and food costs have been reduced. Others considering a project like this must know their clients’ needs and be willing to think outside the box. They should familiarize themselves with current information on systems and equipment, consult with key stakeholders within their organization, and then create the system that will work for them.

American Indian breastfeeding attitudes and practices in Minnesota

OBJECTIVES

We examined the breastfeeding attitudes and practices in an American Indian population in Minnesota.

METHODS

We interviewed women prenatally (n = 380), at 2-weeks (n = 342) and at 6-months postpartum (n = 256). We conducted multivariable analyses to examine the demographic, behavioral, and attitudinal correlates of breastfeeding initiation and duration.

RESULTS

Factors positively associated with breastfeeding initiation included positive breastfeeding attitudes and social support for breastfeeding from the woman's husband/boyfriend and her mother. Factors positively associated with breastfeeding at 2-weeks postpartum were support from the woman's mother and positive attitudes about breastfeeding. The prenatal use of traditional American Indian medicines and cigarette smoking were both significantly associated with breastfeeding at 6-months postpartum.

CONCLUSIONS

Programs to encourage breastfeeding in American Indian communities may be strengthened with protocols to encourage social support, recognition of the perceived health, developmental, and practical benefits of breastfeeding, and a focus on traditional American Indian health practices.