Infant-feeding patterns and cardiovascular risk factors in young adulthood: Data from five cohorts in low- and middle-income countries

Abstract

Infant-feeding patterns may influence lifelong health. This study tested the hypothesis that longer duration of breastfeeding and later introduction of complementary foods in infancy are associated with reduced adult cardiovascular risk.
Data were pooled from 10 912 subjects in the age range of 15-41 years from five prospective birth-cohort studies in low-/middle-income countries (Brazil, Guatemala, India, Philippines and South Africa). Associations were examined between infant feeding (duration of breastfeeding and age at introduction of complementary foods) and adult blood pressure (BP), plasma glucose concentration and adiposity (skinfolds, waist circumference, percentage body fat and overweight/obesity). Analyses were adjusted for maternal socio-economic status, education, age, smoking, race and urban/rural residence and infant birth weight.
There were no differences in outcomes between adults who were ever breastfed compared with those who were never breastfed. Duration of breastfeeding was not associated with adult diabetes prevalence or adiposity. There were U-shaped associations between duration of breastfeeding and systolic BP and hypertension; however, these were weak and inconsistent among the cohorts. Later introduction of complementary foods was associated with lower adult adiposity. Body mass index changed by -0.19 kg/m(2) [95% confidence interval (CI) -0.37 to -0.01] and waist circumference by -0.45 cm (95% CI -0.88 to -0.02) per 3-month increase in age at introduction of complementary foods.
There was no evidence that longer duration of breastfeeding is protective against adult hypertension, diabetes or overweight/adiposity in these low-/middle-income populations. Further research is required to determine whether 'exclusive' breastfeeding may be protective. Delaying complementary foods until 6 months, as recommended by the World Health Organization, may reduce the risk of adult overweight/adiposity, but the effect is likely to be small.

Full text

For Review Only
Infant feeding patterns and cardiovascular risk factors in
young adulthood;
data from five cohorts in low and middle income countries
Journal:
International Journal of Epidemiology
Manuscript ID:
IJE-2010-01-0018.R2
Manuscript Type:
Original Article
Date Submitted by the
Author:
19-Jul-2010
Complete List of Authors:
Fall, CHD; MRC Epidemiology Resource Centre, University of
Southampton
Borja, Judith; Office of Population Studies Foundation, University of
San Carlos
Osmond, Clive; MRc Environmental Epidemiology Unit, University of
Southampton
Richter, Linda; Human Sciences Research Council
Bhargava, Santosh; Sunder Lal Jain Hospital
Martorell, Reynaldo; Hubert Dept of Global Health, Emory
University
Stein, Aryeh; Emory University, Hubert Department of Global
Health
Key Words:
Infant feeding, Breastfeeding, Complementary feeding, Blood
pressure, Diabetes, Body composition
peer-00624429, version 1 - 17 Sep 2011
Author manuscript, published in "International Journal of Epidemiology (2010)"
DOI : 10.1093/ije/DYQ155

For Review Only
1
Infant feeding patterns and cardiovascular risk factors in young adulthood;
data from five cohorts in low and middle income countries
Caroline HD Fall, Judith B Borja, Clive Osmond, Linda Richter, Santosh K Bhargava,
Reynaldo Martorell, Aryeh D Stein, Fernando C Barros, Cesar G Victora, and the
COHORTS group
MRC Epidemiology Resource Centre, University of Southampton, Southampton General
Hospital, Southampton, UK (CHDF, CO); Office of Population Studies Foundation,
University of San Carlos, Cebu City, Philippines (JBB); Human Sciences Research Council,
University of Witwatersrand, South Africa (LR); Sunder Lal Jain Hospital, New Delhi, India
(SKB); Hubert Department of Global Health, Rollins School of Public Health, Emory
University, Atlanta, USA (ADS, RM); Universidade Catolica de Pelotas, Brazil (FCB);
Universidade Federal de Pelotas, Brazil (CGV).
Author for correspondence and reprint requests: Professor Caroline Fall, MRC Epidemiology
Resource Centre, University of Southampton, Southampton General Hospital, Tremona Road,
Southampton SO16 6YD, UK. Tel: 00 44 2380 777624; Fax: 00 44 2380 704021; e-mail
chdf@mrc.soton.ac.uk
Word count: Abstract: 258; Text: 3,701; Tables 5, Figures 2; Online supplementary tables 8,
figures 5.
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ABSTRACT 1
Background Infant feeding patterns may influence lifelong health. This study tested the 2
hypothesis that longer duration of breastfeeding and later introduction of complementary 3
foods in infancy are associated with reduced adult cardiovascular risk. 4
Methods Data were pooled from 10,912 subjects aged 15-41 years from five prospective 5
birth cohort studies in low/middle-income countries (Brazil, Guatemala, India, Philippines, 6
South Africa). Associations were examined between infant feeding (duration of breastfeeding 7
and age at introduction of complementary foods) and adult blood pressure, plasma glucose 8
concentration, and adiposity (skinfolds, waist circumference, percentage body fat, 9
overweight/obesity). Analyses were adjusted for maternal socio-economic status, education, 10
age, smoking, race and urban/rural residence, and infant birthweight. 11
Results There were no differences in outcomes between adults who were ever breastfed 12
compared with those who were never breastfed. Duration of breastfeeding was not associated 13
with adult diabetes prevalence or adiposity. There were U-shaped associations between 14
duration of breastfeeding and systolic blood pressure and hypertension; however these were 15
weak and inconsistent among the cohorts. Later introduction of complementary foods was 16
associated with lower adult adiposity. BMI changed by -0.19 kg/m2 (95%CI -0.37,-0.01) and 17
waist circumference by -0.45 cm (95% CI -0.88,-0.02) per 3-month increase in age at 18
introduction of complementary foods. 19
Conclusions There was no evidence that longer duration of breastfeeding is protective 20
against adult hypertension, diabetes or overweight/adiposity in these low/middle-income 21
populations. Further research is required to determine whether exclusive breastfeeding may be 22
protective. Delaying complementary foods until 6 months, as recommended by WHO, may 23
reduce the risk of adult overweight/adiposity, but the effect is likely to be small. 24
25
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Keywords: Infant feeding, breastfeeding, complementary feeding, blood pressure, diabetes, 1
body composition. 2
3
INTRODUCTION 4
5
The World Health Organisation recommends exclusive breastfeeding from birth to 6 months, 6
the introduction of nutritious complementary foods at 6 months, and continued breastfeeding 7
for >2 years (1). Breastfeeding reduces morbidity and mortality from infection during infancy, 8
and the timely introduction of nutritious complementary foods prevents stunting (2,3). 9
Optimal infant feeding may also have long-term benefits. Adults and children who were 10
breastfed have lower blood pressure, and lower rates of obesity and type 2 diabetes than those 11
who were bottle-fed (4-8), with benefit proportionate to the duration of breastfeeding (9-14). 12
This has been attributed to better appetite regulation and/or lower weight gain in breastfed 13
infants, and/or effects of nutrients or bioactive constituents in breastmilk (6). Fewer studies 14
have investigated long-term associations with the timing of initiation of complementary 15
feeding, but lower rates of childhood obesity have been reported among those who started 16
complementary foods later (15-17). 17
18
A limitation of the published evidence linking breastfeeding to later health is reliance on 19
maternal recall of infant feeding practices, sometimes many years later (6-14). Few studies 20
had data on duration of breastfeeding, and almost none had information on complementary 21
feeding. The majority were conducted in high-income countries, where mothers who follow 22
prescribed infant feeding guidelines tend to be from higher socio-economic and more 23
educated groups (18,19). Associations of infant feeding with later adiposity and other risk 24
factors are usually attenuated after adjusting for these confounding factors, suggesting that 25
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generally healthier family lifestyles, rather than infant feeding, explain the lower disease risk. 1
2
In low- and middle-income countries (LMICs), breastfeeding tends to be the norm, but many 3
mothers introduce complementary foods and stop breastfeeding too early (2). Obesity, 4
diabetes and cardiovascular disease are rising rapidly in these countries (20). Promoting 5
optimal infant feeding practices could be a low-cost intervention to improve lifelong health. 6
Data from LMICs may help address confounding issues, because relationships between infant 7
feeding practices and social class differ from those in high-income settings. The current study 8
analyses data from the COHORTS collaboration (Consortium on Health Orientated Research 9
in Transitional Societies) (21) comprising birth cohort studies in five LMICs. Our objective 10
was to test the hypothesis that initial breastfeeding, longer duration of breastfeeding and later 11
introduction of complementary foods are associated with lower adult blood pressure, glucose 12
concentrations and adiposity. 13
14
SUBJECTS AND METHODS 15
16
Description of the cohorts 17
18
The collaboration among the five cohorts (Table 1) was originally established to contribute a 19
paper for a Lancet series on Maternal and Child Nutrition (22). One author (CGV) 20
approached the principal investigators of all follow-up studies in LMICs with >1000 subjects 21
aged >15 years; all agreed to participate. The cohorts include the 1982 Pelotas (Brazil) Birth 22
Cohort (23); the Institute of Nutrition of Central America and Panama Nutrition Trial Cohort 23
(INTCS, Guatemala) (24); the New Delhi (India) Birth Cohort Study (25); the Cebu 24
(Philippines) Longitudinal Health and Nutrition Survey (CLHNS) (26) and the Birth to 25
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Twenty (BTT - South Africa) cohort (27). The Guatemala cohort was based on a randomised 1
controlled trial of protein-energy supplementation for the pregnant mothers of the cohort 2
members, and for the cohort themselves as young children (24); the others were observational 3
studies. All studies were approved by institutional research ethics committees, and 4
participants gave informed consent. 5
6
Feeding data 7
8
The methods used to collect infant feeding data varied among the cohorts (Table 1). We 9
defined complementary foods as semi-solid or solid foods. Variables used in the analysis were 10
1) whether an individual was ever breast fed (yes/no), available for all 5 cohorts, 2) total 11
duration of breast feeding (9 categories from 0 to >24 months), available for all cohorts 12
except India and 3) age at which complementary feeds were introduced (6 categories from <3 13
to >18 months), available for all cohorts except Guatemala. 14
15
Adult outcomes 16
17
Except for the South African participants who were adolescents (mean age 15 years) all others 18
were young adults. For simplicity, these measures are referred to as “adult” outcomes. 19
20
Systolic (SBP) and diastolic (DBP) blood pressures were measured by aneroid 21
sphygmomanometer in Brazil, mercury sphygmomanometer in the Philippines, and digital 22
devices elsewhere (Guatemala: UA-767, A&D Medical; India: Omron 711; South Africa: 23
Omron M6), using appropriate cuff sizes, after 5-10 minutes seated. The average of two or 24
three measurements was used (21). Hypertension was defined as SBP >140 or DBP >90 25
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mmHg and pre-hypertension as SBP ≥130 or DBP ≥80. In South Africa we defined pre-1
hypertension as SBP or DBP >90th percentile of age-, sex- and height-specific cut points (28). 2
Across all cohorts, less than 0.5% of participants were on anti-hypertensive medication. 3
4
Fasting glucose concentrations were measured in venous plasma (India and South Africa) or 5
capillary plasma (Guatemala) using standard laboratory enzymatic methods, and in venous 6
whole blood (Philippines) using a glucometer (‘One Touch’, Johnson & Johnson Ltd). In 7
Brazil, random finger-prick capillary whole blood glucose was measured by glucometer 8
(Accu-Check Advantage, Roche Ltd); values were adjusted for time since the last meal (29). 9
Glucometers over-estimate glucose concentrations in whole venous blood compared with 10
standard laboratory methods (30,31); we subtracted 0.97 mmol/l from the Philippine values 11
(30). Diabetes was defined as a glucose concentration >7.0 mmol/l, and impaired fasting 12
glucose (IFG) as a concentration >6.1 mmol/l and <7.0 mmol/l) (32). 13
14
Body composition outcomes included body mass index (BMI, weight/height2), waist 15
circumference, body fat percentage, triceps and subscapular skinfolds, overweight (BMI >25 16
kg/m2 ) and obesity (BMI >30 kg/m2 ) (33). Percentage body fat was estimated in Brazil using 17
bioimpedance and a deuterium-validated equation (34); in Guatemala using weight, height 18
and waist circumference with an equation developed using hydrostatic weighing (35); in India 19
and the Philippines using skinfold equations validated for Asian populations (36,37); and in 20
South Africa using dual-energy X-ray absorptiometry (Hologic Delphi). 21
22
Confounding variables 23
24
Earlier research in these cohorts (38-42) indicated that the following should be considered as 25
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possible confounding factors: maternal socio-economic status (SES), education, age, 1
smoking, rural/urban residence and race, and infant birth weight. For SES at birth, a 5-level 2
variable was created for each cohort (1=least and 5=most advantaged), using a principle 3
components analysis of household income and/or assets and services (Brazil, Guatemala, 4
Philippines, South Africa) or the father’s occupation (India). Information on maternal 5
smoking was not available for Guatemala and India, where maternal smoking was almost 6
non-existent at that time; we assumed all were non-smokers. Brazil and South Africa had 7
racial/skin colour sub-groups; we created variables for white, black, mixed race and Asian 8
groups. The Brazil, India and South Africa cohorts are urban, and the Guatemala cohort rural; 9
in the mixed rural and urban Philippine cohort, an ‘urbanicity index’ was used (43). 10
11
Missing data and final analysis sample 12
13
There was minimal missing data in Brazil, the Philippines and South Africa (Table 2). In the 14
Guatemala cohort, age of introduction of complementary foods was not recorded, and 15
duration of breastfeeding was missing for 48% of participants. Missing data arose from the 16
study design; recruitment included pregnant women and children <7 years at baseline; infant 17
feeding was not recorded for children >15 months old at recruitment. Participants with 18
missing data were older, more adipose and more likely to have diabetes or hypertension. In 19
India, duration of breastfeeding was not recorded, and age of introduction of complementary 20
foods was missing for 61% of participants. Those with missing data were younger and less 21
adipose. 22
23
The analysis sample (N=10,912) included participants with data on at least one of the three 24
infant feeding variables and at least one adult outcome (blood pressure, glucose concentration, 25
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body composition), and excluded women who were pregnant at the time of the outcome 1
measurements. 2
3
Statistical methods 4
5
Variables with skewed distributions were log transformed (glucose concentrations, skinfolds). 6
Associations among feeding variables, potential confounders and adult outcomes were 7
assessed within each cohort and in pooled data, using linear or logistic regression or Chi 8
square tests. Categorized duration of breastfeeding and age at introduction of complementary 9
foods were treated as continuous variables in linear regression models, and non-linear 10
associations were tested using quadratic terms. Models were initially adjusted for age and sex 11
only, and then for the set of confounding variables, adult BMI (not done for the adiposity 12
outcomes) and height. Parameter estimates given in the text are fully adjusted. All pooled 13
models were adjusted for cohort location and included interaction terms between cohort 14
location and each confounding variable. We tested for heterogeneity of associations across the 15
five sites by using (for continuous variables) F-tests from nested linear regression models and 16
(for binary outcomes) Chi square tests based on the difference in deviance between nested 17
models; where there was significant heterogeneity (p<0.05), we present data separately for 18
each site. Sex differences were tested using interaction terms. 19
20
RESULTS 21
22
The number of participants included in this analysis, as a percentage of the original live births 23
in each cohort, ranged from 19% in India to 75% in Brazil (Table 1). More than 90% of 24
babies in all cohorts were initially breastfed (Table 2). The most frequent duration of 25
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breastfeeding was 1-3 months in Brazil, 12-18 months in Guatemala and the Philippines, and 1
>2 years in South Africa, and the most frequent age at introduction of complementary foods 2
was 0-3 months in Brazil and South Africa, 3-6 months in the Philippines, and 9-12 months in 3
India. 4
5
Predictors of infant feeding variables 6
7
Associations between the confounding variables and infant feeding variables are presented in 8
additional online material Tables A-G. To summarise these data: in Brazil, women of lower 9
SES/education were less likely to initiate breastfeeding, and tended to breastfeed for either a 10
short or long duration (Tables A&B). In the Philippines and South Africa, women of lower 11
SES/education were more likely to initiate breastfeeding and breastfed for longer. In Brazil, 12
India and the Philippines, more affluent/educated mothers introduced complementary foods 13
earlier. In Brazil and Guatemala women who breastfed for longer tended to be older (Table 14
C). In Brazil and South Africa mothers who smoked (35% and 6% respectively) stopped 15
breastfeeding earlier; the opposite association was seen in the Philippines (13%) (Table D). In 16
Brazil and South Africa there were racial differences in feeding patterns (Table E). In the 17
Philippines, rural mothers were more likely to initiate breastfeeding, breastfed for longer, and 18
introduced complementary foods later (Table F). Babies who were breastfed for a shorter 19
duration tended to have lower birthweight in all cohorts (Table G); in Brazil and India, babies 20
who started complementary foods earlier had higher birthweight. 21
22
Mean age at adult follow-up ranged from 16 years (South Africa) to 32 years (Guatemala) 23
(Table 3). The prevalence of hypertension ranged from 1% (Philippines, females) to 17% 24
(Brazil, males), of diabetes from <1% (Philippines and South Africa) to 4% (Brazil and India, 25
males) and of obesity from 1% (Philippines, females) to 25% (Guatemala, females). 26
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1
Ever v never breastfed 2
3
In the pooled data, there were no differences in blood pressure, glucose or body composition 4
outcomes between participants who were initially breastfed compared with those not 5
breastfed (Tables 4&5). There was heterogeneity between sites for diastolic blood pressure 6
(Table 4); in Brazil DBP was lower among participants who were breastfed (-1.5 mmHg, 95% 7
CI -2.7,-0.3), while in the Philippines and South Africa there was a trend in the opposite 8
direction (Philippines: +1.3 mmHg, 95% CI -0.5,3.1; South Africa: +1.4 mmHg, 95% CI 9
0.6,2.2). There was also heterogeneity between sites for prevalence of overweight (Table 5), 10
with a lower risk in Brazil among participants who were breastfed (OR 0.76, 95% CI 0.59 to 11
0.98), and opposite trends in the Philippines (OR 1.4, 95% CI 0.4 to 2.8) and South Africa 12
(OR 1.4, 95% CI 0.5 to 4.2). 13
14
Breastfeeding duration 15
16
In the pooled data, there were U-shaped associations between breastfeeding duration and all 17
the blood pressure outcomes (Table 4, Figure 1). For SBP and hypertension, these remained 18
after adjustment for confounding factors, adult BMI and height. The lowest mean blood 19
pressures were observed among participants who had been breastfed for 3-6 months; there 20
was a difference of approximately 2 mmHg between the lowest and highest mean values 21
(Figure 1). Several of these U-shaped associations showed borderline heterogeneity across the 22
cohorts (Table 4). A U-shaped association was clear only in Brazil (Figure 1); there was an 23
upward trend in Guatemala, and no apparent trends with duration of breastfeeding in the 24
Philippines and South Africa. After excluding the Brazil data, there were no linear or U-25
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shaped associations between breastfeeding duration and any blood pressure outcome. 1
2
There was no heterogeneity among the cohorts for glucose or body composition outcomes. 3
There was a U-shaped association between breastfeeding duration and IFG+DM (Table 4), 4
and an inverse association between breastfeeding duration and adult skinfold thickness (Table 5
5). However, these associations were attenuated after adjusting for confounding variables. 6
7
There were no changes in the findings if the Guatemala cohort, in which duration of 8
breastfeeding was missing for 48% of participants, was excluded from the analysis. In the 9
Guatemala data, there was an interaction between intervention group and duration of 10
breastfeeding for only one outcome (adult BMI); there were no changes in the findings when 11
the two intervention groups were considered as separate populations. 12
13
Introduction of complementary foods 14
15
The age at introduction of complementary foods was unrelated to the blood pressure and 16
glucose outcomes (Table 4). There was no significant heterogeneity among the cohorts. 17
Later introduction of complementary foods was associated with lower adult BMI, waist 18
circumference and percentage body fat, thinner skinfolds, and a lower risk of 19
overweight/obesity (Table 5, Figure 2). The findings were similar after excluding the India 20
cohort, which had a higher mean age at introduction of complementary foods, and in which 21
data were missing for 61% of participants. Inverse associations were still present for BMI, 22
waist circumference and subscapular skinfolds, which fell by 0.19 kg/m2 (95% CI 0.01,0.37), 23
0.45 cm (95% CI 0.02,0.88), and 3.1% (95% CI 0.6,5.4; the percentage change in skinfolds is 24
cited here rather than the change in mm, because the skinfold values were logged for analysis 25
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) respectively per category increase in age of introduction of complementary foods. When the 1
analysis was limited to the period up to 6 post-natal months, these associations were 2
attenuated; BMI, waist circumference and subscapular skinfold thickness fell by 0.21 (95% CI 3
-0.03 0.45), 0.45 cm (95% CI -0.11, 1.01) and 2.6% (95% CI -0.9, 6.1) respectively per 3-4
month category. 5
6
Earlier introduction of complementary foods was associated with higher infant weight at 2 7
years (additional online material Table H). After adjusting for 2-year weight, the inverse 8
associations between age of introduction of complementary feeds and adult adiposity were no 9
longer present. 10
11
There was no consistent evidence of differences according to sex, or the age at which 12
outcomes were measured, in any of the associations described. 13
14
Associations of duration of breastfeeding and age of introduction of complementary foods 15
with selected outcomes are presented by individual cohort in additional online material 16
Figures J-N. 17
18
DISCUSSION 19
20
We combined data from five birth cohorts in low- and middle-income countries, to examine 21
associations between infant feeding and risk factors for cardiovascular disease (blood 22
pressure, glucose concentrations and adiposity) in over 10,000 young adults. There were no 23
differences in risk factors between participants who were initially breastfed compared to those 24
who were never breastfed. There were U-shaped associations between duration of 25
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breastfeeding and adult blood pressure, with the lowest mean systolic blood pressure among 1
those breastfed for 3-6 months; however these were small and inconsistent effects. After 2
adjusting for confounding factors, there were no associations between duration of 3
breastfeeding and adult glucose concentrations, DM+IFG or body composition. Participants 4
who started complementary foods later in infancy were less adipose and overweight in adult 5
life. These associations were robust to adjustment for the set of confounding variables, but 6
attenuated by adjustment for 2-year weight. 7
8
Strengths of the study were that infant feeding data were collected prospectively, reducing the 9
risk of misclassification due to inaccurate maternal recall, and included duration of 10
breastfeeding and introduction of complementary foods. Limitations were missing infant 11
feeding data and losses to follow-up in the older Guatemala and India cohorts. Missing data 12
would influence population means and prevalence values for both exposures and outcomes, 13
but the within-cohort associations of interest, between infant feeding and adult outcomes, 14
would be less vulnerable to bias. Associations of duration of breastfeeding and age of 15
introduction of complementary foods were little changed if the Guatemala and India cohorts 16
were excluded from the relevant analyses. A further limitation of the study was heterogeneity 17
among the cohorts in the methods for recording infant feeding data. This reduced the number 18
of exposures we could include (for example, exclusive breastfeeding and predominant 19
breastfeeding were definable in only 1 and 3 of the cohorts respectively and were not 20
included), and we defined introduction of complementary feeds as the introduction of solids 21
rather than nutritious liquids and solids, the more generally used definition. The different 22
methods would tend to reduce the precision of the exposure variables and thus attenuate any 23
estimates of association with adult outcomes. The methods used for measuring adult 24
outcomes also varied among the cohorts, although are all accepted techniques for 25
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epidemiological studies. Blood pressure was measured using a variety of devices, all of which 1
perform to international standards, although systematic under- or over-estimation of blood 2
pressure is recognised (44-47). Blood glucose was measured using standard laboratory assays 3
or by glucometers, and although the latter are not recommended for clinical diagnosis of 4
individual patients, their use in epidemiological studies is accepted (48). Four studies 5
measured fasting glucose; the Pelotas study used random glucose, adjusted for time since the 6
last meal (29). Adiposity was measured using similar anthropometric protocols in all studies, 7
and percentage body fat was measured using a variety of techniques that have been validated 8
in appropriate populations. Different techniques would influence the precision of 9
measurements, which could obscure associations but is unlikely to create spurious 10
associations. Systematic over-/under- estimation of (say) blood pressure or the prevalence of 11
hypertension would not affect the ranking of the participants, and would not, therefore, 12
substantially change the associations of interest. 13
14
A consistent finding was that later introduction of complementary foods was associated with 15
lower adult adiposity. Previous literature on this topic is mixed; some studies have reported 16
findings similar to ours (15-17). Others have reported no association (4,49,50) or an opposite 17
association (51). In our pooled data there was a linear decrease in adult adiposity across the 18
range of ages at which complementary foods were started (<3 months to >18 months) (Figure 19
2). Introduction of complementary foods later than 6 months is associated with nutritional 20
inadequacy and growth faltering (1,2) and cannot be recommended. However, in our data, 21
there was a downward trend in adiposity with later introduction of complementary foods even 22
in the first 6 post-natal months (Figure 2), though this was very small and likely to be of 23
limited health significance. Earlier introduction of complementary foods is associated with 24
greater infant weight gain (52), and our results, showing no association after adjusting for 2-25
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year weight, suggest that this could be a mediating factor. 1
2
There were no differences in outcomes between ‘ever’ versus ‘never’ breastfed groups. This 3
contrasts with results from meta-analyses of observational studies, mainly in high-income 4
settings, which have shown lower systolic (around -1 mmHg) and diastolic blood pressure (<-5
0.5 mmHg), a 30-40% lower risk of type 2 diabetes and a 20% lower risk of overweight or 6
obesity in children or adults who were breastfed (6-9). Possible explanations for our negative 7
findings are that initiation of breastfeeding was almost universal in these cohorts (hence 8
reducing power), and/or that the associations in the above studies result from residual 9
confounding, not seen in our cohorts because of the different relationships between infant 10
feeding and maternal SES. 11
12
There were U-shaped associations between duration of breastfeeding and blood pressure 13
outcomes. These trends were inconsistent among the 5 cohorts (Figure 1). Overall, there was 14
no evidence that longer duration of breastfeeding protects against the later development of 15
hypertension or diabetes. Again, these findings differ from those reported from high-income 16
settings, where most studies (9,10,12,53,54), though not all (55,56), found lower blood 17
pressure and/or a lower risk of type 2 diabetes in children or adults who were breastfed for 18
longer. Explanations could be, again, residual confounding in high-income populations; 19
imprecision in the exposure measure due to different data collection methods; or differences 20
in other post-natal factors related to the adult outcomes, for example childhood growth, 21
between low- and high-income populations. 22
23
A recent systematic review of studies in children and adults found a linear inverse association 24
between duration of breastfeeding and risk of overweight/obesity in about half the studies 25
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(14). The associations were diminished after adjusting for confounders, but remained in some 1
studies. We found that participants who were breastfed for longer in infancy had thinner 2
skinfolds, but the associations were attenuated by adjusting for confounding variables. 3
Confounding has been a major limitation of studies linking infant feeding to later health. The 4
ultimate solution to this problem would be randomised controlled trials, but it is not possible 5
to randomize healthy babies into breastfed and non-breastfed groups. Helpful data will come 6
from a large randomised trial of breastfeeding promotion, in Belarus, which greatly increased 7
initiation rates and duration of breastfeeding (57). In this trial, there were no differences in 8
blood pressure or adiposity between children from the intervention and control groups at 9 9
years. In another trial, among pre-term newborns, there was no difference in blood pressure in 10
childhood between those randomised to receive breast milk or formula (58), but blood 11
pressure was lower in the breast milk group in adolescence (59). We know of no randomised 12
trials of early versus late introduction of complementary foods. 13
14
In conclusion, in 5 high-quality birth cohorts in low- and middle-countries, we found no 15
evidence that initial breastfeeding, or longer duration of breastfeeding, were protective against 16
adult hypertension, diabetes or overweight/obesity. There are many proven benefits of 17
breastfeeding, but the evidence that it reduces the risk of adult chronic disease is not 18
compelling, at least in LMICs. We were not, however, able to examine exclusive 19
breastfeeding as an exposure, since this was available for only one of the cohorts. There was a 20
consistent linear inverse association between age of introduction of complementary foods and 21
adult adiposity. Our data suggest there may be modest protection against adult adiposity from 22
delaying the introduction of complementary foods to the recommended 6 months. This 23
association should be examined in other studies. 24
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Funding support: The COHORTS collaboration is funded by the Wellcome Trust, UK. 1
Funding sources for each of the COHORTS sites are as follows: Brazil: Wellcome Trust. 2
Guatemala: US National Institutes of Health, US National Science Foundation, Nestle 3
Foundation, Thrasher Foundation and American Heart Association. India: US National Center 4
for Health Statistics, Indian Council of Medical Research, British Heart Foundation, Medical 5
Research Council UK. The Philippines: US National Institutes of Health, Fogarty 6
International Center. South Africa: Wellcome Trust, Human Sciences Research Council, 7
South African Medical Research Council, Mellon Foundation, South-African Netherlands 8
Programme on Alternative Development and the Anglo American Chairman’s Fund. All 9
authors/researchers are independent of the funding bodies. 10
11
*COHORTS group members not included as named authors for this paper: 12
Denise Gigante, Pedro Hallal and Bernardo Horta (Universidade Federal de Pelotas, Brazil), 13
Manuel Ramirez-Zea (Institute of Nutrition of Central America and Panama, Guatemala City, 14
Guatemala), Andrew Wills (MRC Epidemiology Resource Centre, University of 15
Southampton, Southampton, UK), Harshpal Singh Sachdev (Sitaram Bhartia Institute of 16
Science and Research, New Delhi, India), Linda Adair (University of North Carolina at 17
Chapel Hill, Chapel Hill, USA), Darren Dahly (University of Leeds, UK), Christopher 18
Kuzawa (Department of Anthropology, Northwestern University, Illinois, USA), Shane 19
Norris, Daniel Lopez and Mathew Mainwaring (Department of Paediatrics, MRC Mineral 20
Metabolism Research Unit, University of the Witwatersrand, Johannesburg, Bt20). 21
22
Special thanks to other major contributors to the 5 studies: Brazil: Rosangela Lima 23
(Universidade Católica de Pelotas); India: Lakshmi Ramakrishnan, Nikhil Tandon (All-India 24
Institute of Medical Sciences, New Delhi), Dorairaj Prabhakaran (Centre for the Control of 25
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Chronic Diseases, New Delhi), Siddharth Ramji (Maulana Azad Medical College, New 1
Delhi), K Srinath Reddy (Public Health Foundation of India); SK Dey Biswas (Indian Council 2
of Medical Research); Vinod Kapani (Bureau of Labor Statistics, Washington DC, USA); 3
Guatemala: Ann DiGirolamo Rafael Flores (US Centers for Disease Control), Usha 4
Ramakrishnan, Kathryn Yount (Emory University), Ruben Grajeda (PAHO), Paul Melgar, 5
Humberto Mendez, Luis Fernando Ramirez (INCAP), Jere Behrman (University of 6
Pennsylvania), John Hoddinott, Agnes Quisumbing, Alexis Murphy (IFPRI), John Maluccio 7
(Middlebury College); Philippines: Barry Popkin (University of North Carolina at Chapel 8
Hill), Sororro Gultiano, Josephine Avila, Lorna Perez (Office of Population Studies 9
Foundation, University of San Carlos, Cebu), ThomasMcDade (Northwestern University); 10
South Africa: Noel Cameron (Loughborough University, UK), John Pettifor (University of 11
Witwatesrand). The manuscript and figures were prepared by Jane Pearce. 12
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REFERENCES
1. Daelmans B, Martines J, Saadeh R (Eds). Special Issue Based on a World Health
Organization Expert Consultation on Complementary Feeding. Food Nutr Bulletin
2003;24:1-134.
2. Black RE, Allen LH, Bhutta Z et al. Maternal and child undernutrition: global and
regional exposures and health consequences. Lancet 2008;371:243-60.
3. Bhutta Z, Ahmad T, Black RE et al. What works? Interventions to affect maternal and
child undernutrition and survival globally. Lancet 2008;371:417-40.
4. Kramer MS. Do breast-feeding and delayed introduction of solid foods protect against
subsequent obesity? J Pediatrics 1981;98:883-887.
5. Horta BL, Bahl R, Martines JC, Victora CG. Evidence on the long-term effects of
breastfeeding: systematic reviews and meta-analyses. Geneva: WHO, 2007. (ISBN
978-92-4-159523-0).
6. Owen CG, Whincup PH, Gilg JA, Cook DG. Effect of breast feeding in infancy on
blood pressure in later life: systematic review and meta-analysis. BMJ 2003;327:1189-
95.
7. Owen CG, Martin RM, Whincup PH, Davey Smith G, Cook DG. Does breastfeeding
influence the risk of type 2 diabetes in later life? A quantitative analysis of published
Page 19 of 49
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
peer-00624429, version 1 - 17 Sep 2011

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20
evidence. AJCN 2006;84:1043-54.
8. Owen CG, Martin RM, Whincup PH, Davey Smith G, Cook DG. Effect of infant
feeding on the risk of obesity across the life course: a quantitative review of published
evidence. Pediatrics 2005;115:1367-77.
9. Taittonen L, Nuutinen M, Turtinen J, Uhari M. Prenatal and postnatal factors in
predicting later blood pressure among children: cardiovascular risk in young Finns.
Ped Res 1996;40:627-32.
10. Lawlor DA, Riddoch CJ, Page AS et al. Infant feeding and components of the
metabolic syndrome: findings from the European Youth Heart Study. Arch Dis Child
2005;90:582-8.
11. Martin RM, Ben-Shlomo Y, Gunnell D, Elwood P, Yarnell JWG, Davey Smith G.
Breast feeding and cardiovascular disease risk factors, incidence, and mortality: the
Caerphilly Study. J Epidemiol Community Health 2005;59:121-9.
12. Young TK, Martens PJ, Taback SP et al. Type 2 diabetes mellitus in children; prenatal
and early infancy risk factors among Native Canadians. Arch Pediatr Adolesce Med
2002;156:651-5.
13. Rich-Edwards JW, Stampfer MJ, Manson JE et al. Breastfeeding during infancy and
the risk of cardiovascular disease in adulthood. Epidemiology 2004;15:550-6.
Page 20 of 49
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2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
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23
24
25
26
27
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47
48
49
50
51
52
53
54
55
56
57
58
59
60
peer-00624429, version 1 - 17 Sep 2011

For Review Only
21
14. Arenz S, Ruckerl R, Koletzko B, von Kries R. Breastfeeding and childhood obesity; a
systematic review. Int J Obes Relat Metab Disord 2004;28:1247-54.
15. Wilson AC, Forsyth JS, Greene SA, Irvine L, Hau C, Howie PW. Relation of infant
diet to childhood health: seven year follow up of cohort of children in Dundee infant
feeding study. BMJ 1998;316:21-25.
16. Reilly JJ, Armstrong J, Dorosty AR et al. Early life risk factors for obesity in
childhood: cohort study. BMJ 2005;330:1357.
17. Hawkins SS, Cole TJ, Law CM and the Millennium Cohort Study Child Health
Group. An ecological systems approach to examining risk factors for early childhood
overweight: findings from the UK Millennium Cohort Study. J Epidemiol Community
Health 2009;63:147-55.
18. Heck KE, Braveman P, Cubbin C, Chavez GF, Kiely JL. Socioeconomic status and
breastfeeding initiation among California mothers. Public Health Rep 2006;121:51-59.
19. Bolling K, Grant C, Hamlyn B. Infant Feeding Survey 2005. London: The Information
Centre, 2007.
20. Fall CHD. Non-industrialised countries and affluence. In Type 2 Diabetes: the thrifty
phenotype. Ed DJP Barker. Brit Med Bull 2001;60:33-50.
21. Adair LS, Martorell R, Stein AD et al. Size at birth, weight gain in infancy and
Page 21 of 49
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
peer-00624429, version 1 - 17 Sep 2011

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22
childhood and adult blood pressure in five low and middle income country cohorts:
When does weight gain matter? AJCN 2009;89:1383-92.
22. Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, Sachdev HPS and the
Maternal and Child Undernutrition Study Group. Maternal and child undernutrition:
consequences for adult health and human capital. Lancet 2008; 371: 340-357.
23. Victora CG, Barros FC. Cohort profile: the 1982 Pelotas (Brazil) birth cohort study.
Int J Epidemiol 2006;35:237-42.
24. Stein AD, Melgar P, Hoddinott J, Martorell R. Cohort Profile: the Institute of
Nutrition of Central America and Panama (INCAP) Nutrition Trial Cohort Study. Int J
Epidemiol 2008;37:716-20.
25. Bhargava SK, Sachdev HS, Fall CH, et al. Relation of serial changes in childhood
body-mass index to impaired glucose tolerance in young adulthood. N Engl J Med
2004;350:865-75.
26. Adair LS. Size at birth and growth trajectories to young adulthood. Am J Hum Biol
2007;327-37.
27. Richter L, Norris S, Pettifor J, Yach D, Cameron N. Cohort Profile: Mandela's
children: the 1990 Birth to Twenty study in South Africa. Int J Epidemiol
2007;36:504-11.
Page 22 of 49
1
2
3
4
5
6
7
8
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11
12
13
14
15
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48
49
50
51
52
53
54
55
56
57
58
59
60
peer-00624429, version 1 - 17 Sep 2011

For Review Only
23
28. National High Blood Pressure Education Program Working Group on High Blood
Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation,
and treatment of high blood pressure in children and adolescents. Pediatrics
2004;114:555-76.
29. Horta BL, Gigante DP, Victora CG, Barros FC, Oliveira I, Silveira V. Early
determinants of random blood glucose among adults of the 1982 birth cohort, Pelotas,
Southern Brazil. Rev Saude Publica 2008; 42 (Suppl 2): 93-100.
30. Kumar G, Sng BL, Kumar S. Correlation of capillary and venous glucometry with
laboratory determination. Prehosp Emerg Care 2004;8:378-83.
31. Petersen JR, Graves DF, Tacker DH, Okurodudu AO, Mohammad AA, Cardenas VJ.
Comparison of POCT and central laboratory blood glucose results using arterial,
capillary, and venous samples from MICU patients on tight glycaemic control. Clinica
Chimica Acta 2008;396:10-13.
32. World Health Organisation. Definition, diagnosis and classification of diabetes
mellitus and its complications. Report of a WHO consultation. Part 1: DDDiagnosis
and Classification of Diabetes Mellitus. WHO, Geneva, 1999.
33. Physical status: the use and interpretation of anthropometry. WHO Technical report
series No 854. WHO, Geneva, 1995.
34. Wells JCK, Gigante D, Wright A, Hallal PC, Victora CG. Validation of leg-to-leg
Page 23 of 49
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
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21
22
23
24
25
26
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28
29
30
31
32
33
34
35
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37
38
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51
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53
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57
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impedance for body composition assessment in male Brazilians aged 16-19 years.
International Journal of Body Composition Research 2003;1:69-75.
35. Ramirez-Zea M, Torun B, Martorell R, Stein AD. Anthropometric predictors of body
fat as measured by hydrostatic weighing in Guatemalan adults. Am J Clin Nutr
2006;83:795-802.
36. Durnin JV, Womersley J. Body fat assessed from total body density and its estimation
from skinfold thickness: measurements on 481 men and women aged from 16 to 72
years. Br J Nutr 1974;32:77-97.
37. Deurenberg P, Deurenberg-Yap M. Validation of skinfold thickness and hand-held
impedance measurements for estimation of body fat percentage among Singaporean
Chinese, Malay and Indian subjects. Asia Pac J Clin Nutr 2002;11:1-7.
38. Araujo CL, Victora CG, Hallal PC, Gigante DP. Breastfeeding and overweight in
childhood, evidence from the Pelotas 1993 birth cohort study. Int J Obesity
2006;30:500-6.
39. Sellen DW, Thompson AL, Hruschka DJ, Stein AD, Martorell R. Early determinants
of non-exclusive breastfeeding among Guatemalan infants. Adv Exp Med Biol
2004;554:299-301.
40. Ghosh S, Gidwani S, Mittal SK, Verma RK. Socio-cultural factors affecting
breastfeeding and other infant feeding practices in an urban community. Indian
Page 24 of 49
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2
3
4
5
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7
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11
12
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Pediatrics 1976;13:827-32.
41. Daniels MC, Adair L. Breastfeeding influences cognitive development in Filipino
children. J Nutr 2005;135:2589-95.
42. Ellison GT, Wagstaff L, Cameron N, de Wet T. Geographical differences in infant
feeding patterns in disadvantaged communities. S African Med J 1997;87:1025-6.
43. Adair L, Dahly D. Quantifying the urban environment; a scale measure of urbanicity
outperforms the rural-urban dichotomy. Soc Sci Med 2007;64:1407-19.
44. Ma Y, Temprosa M, Fowler S, Prineas RJ, Montez MG, Brown-Friday J, Carrion-
Petersen ML, Whittington T. Evaluating the accuracy of an aneroid
sphygmomanometer in a clinical trial setting. Am J Hyperten 2009:22:263-266.
45. Rogoza AN, Pavlova TS, Sergeeva MV. Validation of A&D UA-767 device for the
self-measurement of blood pressure. Blood Pressure Monitoring 2000:5: 227-231.
46. Grim CE, Grim CM. Omron HEM-711 DLX home blood pressure monitor passes the
European Society of Hypertension International Validation Protocol. Blood Pressure
Monitoring 2008:13: 225-226.
47. Altunkan S, Ilman N, Kayaturk N, Altunkan E. Validation of the Omron M6 (HEM-
7001-E) upper-arm blood pressure measuring device according to the International
Protocol in adults and obese adults. Blood Pressure Monitoring 2007:12: 219-225.
Page 25 of 49
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51
52
53
54
55
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57
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48. World Health Organisation. Definition and diagnosis of diabetes mellitus and
intermediate hyperglycaemia. Report of a WHO/IDF consultation. World Health
Organization, Geneva, 2006.
49. Burdette HL, Whitaker RC, Hall WC, Daniels ST. Breastfeeding, introduction of
complementary foods, and adiposity at 5 y of age. AJCN 2006;83:550-8.
50. Zive MM, McKay H, Frank-Spohrer GC, Broyles SL, Nelson JA, Nader PR. Infant-
feeding practices and adiposity in 4-y-old Anglo- and Mexican-Americans. AJCN
1992;55:1104–8.
51. Agras WS, Kraemer HC, Berkowitz RI, Hammer LD. Influence of early feeding style
on adiposity at 6 years of age. J Pediatr 1990;116:805–9.
52. Baker JL, Michaelsen KF, Rasmussen KM, Sorenson TI. Maternal prepregnant body
mass index, duration of breastfeeding, and timing of complementary food introduction
are associated with infant weight gain. AJCN 2004;80:1579-88.
53. Martin RM, Ness AR, Gunnell D, Emmett P, Davey Smith G and the ALSPAC study
team. Does breast-feeding in infancy lower blood pressure in childhood?; the Avon
Longitudinal Study of Parents and Children (ALSPAC). Circulation 2004;109:1259-
66.
54. Mayer-Davis EJ, Dabelea D, Lamichhane AP et al. Breastfeeding and type 2 diabetes
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in the youth of three ethnic groups: the SEARCH for diabetes in youth case-control
study. Diabetes Care 2008;31:470-5.
55. Davis JN, Weigensberg MJ, Shaibi GQ et al. Influence of breastfeeding on obesity and
type 2 diabetes risk factors in Latino youth with a family history of type 2 diabetes.
Diabetes Care 2007;30:784-9.
56. Wadsworth M, Marshall S, Hardy R, Paul A. Breastfeeding and obesity; relation may
be accounted for by social factors. BMJ 1999;319:1576.
57. Kramer MS, Matush L, Vanilovich I et al. Effects of prolonged and exclusive
breastfeeding on child height, weight, adiposity, and blood pressure at age 6.5 years:
evidence from a large randomised trial. AJCN 2007;86:1717-21.
58. Lucas A, Morley R. Does early nutrition in infants born before term programme later
blood pressure? BMJ 1994;309:304-8.
59. Singhal A, Cole TJ, Lucas A. Early nutrition in preterm infants and later blood
pressure: two cohorts after randomised trials. Lancet 2001; 357: 413-9.
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Key messages box
• Previous research suggests that optimal breastfeeding and complementary feeding
practices during infancy may reduce the risk of adult obesity, hypertension and type 2
diabetes.
• This evidence, mainly from high-income populations, is controversial because of
confounding factors such as socio-economic status. We present data from 5 adult birth
cohorts in low/middle-income settings
• We found no evidence that a longer duration of breastfeeding was associated with
reduced adult adiposity, blood pressure or plasma glucose concentrations.
• Later introduction of complementary foods (solids) was associated with a small
reduction in adult BMI, waist circumference and skinfold thickness.
.
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Table 1: Characteristics of the 5 cohort studies and how infant feeding data were collected
COHORT
name
Design
Cohort inception
(year) and initial sample (N)
Last follow-up visit (year)
and number examined (N)
Number included in this
analysis (N) and percentage
of original cohort
Initial cohort
How the infant feeding data were
collected
Ever breast fed
Total duration of
any breastfeeding
Duration predominant
breastfeeding
Duration exclusive
breastfeeding
Age at introduction of
complementary foods
Pelotas,
Brazil22
Prospective
cohort
1982
5,914
2005
4,297
4,446
(75%)
Children born in the
city’s maternity
hospital (>99% of all
births) in 1982. All
social classes included.
Mothers were asked at 6, 12, 20 & 48
months if they were breastfeeding and, if
not, when they stopped. At 12 months (33%
sub-sample) and 20 months (full cohort)
they were asked at what age other liquids
and foods were added (separately for other
milks, herbal teas, juices, fruits, legumes,
full family foods), ‘Predominant’
breastfeeding was defined as breastmilk
plus water or herbal teas only. Data from
earlier visits were used preferentially.
YES YES YES NO YES
INTCS,
Guatemala
23
Community
trial
1969-
77
2,392
2004
1,571
1,272
(53%)
Intervention trial of a
high-energy and protein
supplement in women,
and children <7 yrs in
1969 and born during
1969-1977 in 4
villages.
Mothers were asked every 15 days, starting
at birth, if they were breastfeeding. From
the age of 15 months to 5 years, 24-hour
recalls were performed every 3-6 months to
record detailed dietary intakes.
YES YES NO NO NO
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New Delhi,
India24
Prospective
cohort
1969-
1972
8,181
1998-
2002
1,583
1,526
(19%)
Babies born to an
identified population of
married women living
in a defined area of
Delhi. Primarily
middle-class sample.
At each visit (birth, 3, 6, 9, 12, 18 & 24
months) project staff assigned babies to the
highest applicable category from: 1)
Entirely breastfed; 2) Breast+bottle fed; 3)
Entirely bottle fed; 4) First solids; 5) 3-4
solid foods; 6) Adult diet. For example, if
an infant had just started solid feeds, they
were classified as category 4, even if they
were still receiving breast milk.
YES NO NO NO YES
CLHNS
Philipp-
ines25
Prospective
cohort
1983-
1984
3,080
2005
2,032
2,048
(66%)
Pregnant women living
in 33 randomly selected
neighbourhoods; 75%
urban. All social classes
included.
Data were collected every 2 months from 0-
24 months, to determine if the baby was
breastfed and whether it was fed any other
foods/liquids. At each 2-monthly visit, a 24-
hour recall of all foods and liquids was
performed, allowing quantification of
nutrient intakes.
YES YES YES YES YES
Birth-to-
twenty
South
Africa26
Prospective
cohort
1990
3,273
2005
2,100
1,620
(49%)
Babies born to pregnant
women living in a
defined urban
geographical area.
Predominantly poor,
black sample.
Questionnaires were administered at 3, 6,
12 & 24 months. Mothers were asked if
they had ever breastfed the baby; if they
were still breastfeeding; if stopped, when
they stopped; and if and when a) other milk
feeds and b) semi-solid or solid foods were
introduced.
YES YES YES NO YES
Variables
used in this
analysis
YES YES NO NO YES
In Brazil and the Philippines, the number included in this analysis exceeds the number of participants in the last follow-up study, because some data (for example height) was
utilised from previous follow-up rounds.
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Table 2 Patterns of infant feeding in the 5 cohorts
Brazil
N=4,446
Guatemala
N=1,272
India
N=1,526
Philippines
N=2,048
South Africa
N=1,620
Ever breastfed N (%)
Yes
3964
(92.2)
739
(99.7)
1446
(99.9)
1934
(94.9)
1519
(94.9)
No 336
(7.8) 2
(0.3) 2
(0.1) 104
(5.1) 81
(5.1)
Data missing (N) 146
531
78
10
20
Duration of breastfeeding (months) N (%)
None 336
(7.8) 2
(0.3) No 104
(5.1) 81
(5.7)
0.01-1.00 997
(23.2) 2
(0.3) data 120
(5.9) 103
(7.3)
1.01-3.00 1282
(29.8) 2
(0.3) on 113
(5.5) 207
(14.6)
3.01-6.00 621
(14.4) 12
(1.8) duration 134
(6.6) 145
(10.2)
6.01-9.00 290
(6.7) 39
(5.8) of 106
(5.2) 94
(6.6)
9.01-12.00 164
(3.8) 60
(8.9) breast 163
(8.0) 110
(7.8)
12.01-18.00 176
(4.1) 258
(38.1) feeding 563
(27.6) 194
(13.7)
18.01-24.00 55
(1.3) 197
(29.1) 440
(21.6) 170
(12.0)
>24.00 379
(8.8) 105
(15.5)
295
(14.5) 315
(22.2)
Data missing (N) 146
595
10
201
Age of introduction of complementary foods (months) N (%)
0-3.00 2874
(69.4) No 0
(0.0) 117
(5.9) 922
(58.3)
3.01-6.00 1167
(28.2) data 6
(1.0) 1630
(81.7) 592
(37.4)
6.01-9.00 81
(2.0) on 50
(8.3) 238
(11.9) 53
(3.4)
9.01-12.00 22
(0.5) age 254
(42.2) 10
(0.5) 12
(0.8)
12.01-18.00 0
(0.0) complementary
220
(36.5) 0
(0.0) 1
(0.1)
> 18.00 0
(0.0) foods 72
(12.0) 0
(0.0) 1
(0.1)
Data missing (N) 302
introduced 924
53 39
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Table 3 Characteristics of the cohort at adult follow-up
BRAZIL GUATEMALA INDIA PHILIPPINES SOUTH AFRICA
Men Women Men Women Men Women Men Women Men Women
Mean(SD) Mean(SD) Mean(SD) Mean(SD) Mean(SD)
Mean
(SD) Mean(SD) Mean(SD) Mean(SD) Mean(SD)
Age 22.7(0.4) 22.7(0.4) 32.3(4.1) 32.5(4.1) 29.2(1.3) 29.2(1.4) 21.3(0.8) 21.1(1.0) 15.6(0.3) 15.6(0.3)
Blood Pressure Outcomes
N 2208 1980 578 634 880 631 1080 962 753 834
SBP (mm Hg) 123(14) 111(13) 117(11) 108(131) 118(11) 107(11) 112(11) 99(10) 118(13) 111(12)
DBP (mm Hg) 76(12) 72(11) 72(9) 70(9) 78(10) 73(9) 76(10) 68(9) 68(10) 69(9)
Hypertension (%)
16.7 5.9 5.2 3.3 12.2 5.2 10.8 1.1 7.3 4.0
Pre-hypertension
(%)
43.2 22.2 24.0 13.9 43.6 24.7 44.8 11.2 41.4 25.1
Glucose Outcomes
N 1856 1758 437 558 869 623 933 837 570 616
Glucose
(mmol/l)*
5.5(5.0,5.9) 5.2(4.8,5.6)
5.1(4.8,5.4) 5.1(4.7,5.4) 5.4(4.9,5.9) 5.3(4.8,5.8) 4.7(4.4,5.0) 4.5(4.2,4.8) 5.1(4.8) 4.9(4.6,5.2)
Diabetes (%) 4.3 3.2 1.8 3.6 3.7 3.4 0.3 0 0.4 0.2
IFG (%)
19.4 12.4 5.3 7.2 20.5 14.4 0.9 1.0 2.6 1.9
Body Composition
N 2207 1979 557 594 886 640 1079 958 753 831
Height (cm) 173.7(6.9) 160.8(6.2) 162.8(6.0) 150.7(5.6) 169.7(6.4) 154.9(5.7) 163.0(5.8) 151.2(5.5) 166.3(8.1) 158.7(6.2)
BMI (kg/m2) 23.8(4.1) 23.4(4.6) 24.7(3.6) 27.0(4.8) 24.9(4.3) 24.6(5.1) 21.0(3.1) 20.2(3.1) 19.7(3.4) 22.1(4.5)
Waist (cm) 80.9(10.1) 74.9(10.6) 86.7(9.1) 92.3(12.1) 90.2(12.1) 79.6(12.4) 72.0(7.5) 67.6(7.2) 69.7(8.3) 71.1(9.6)
Fat (%) 16.3(3.8) N/A 20.5(6.6) 35.1(7.3) 24.2(5.9) 34.2(7.0) 16.7(5.1) 32.7(4.8) 15.7(7.8) 32.1(7.2)
Subscapular
skinfold (mm)*
9.8(8.2,13.0) N/A 12.9(9.2,18.6)
22.3(16.2,28.2)
23.0(16.3,30.3)
25.4(17.5,34.2)
11.0(9.0,14.0) 17.3(13.3,21.7)
N/A N/A
Triceps skinfold
(mm)*
8.8(6.8,13.0) N/A 8.6(6.2,11.6)
20.1(15.4,24.6)
16.3(11.1,21.1)
26.1(18.1,32.7)
9.0(7.0,13.7) 19.3(15.7,24.0)
N/A N/A
Overweight (%) 30.6 26.0 40.4 62.6 47.3 45.1 9.7 7.5 7.9 23.2
Obese (%)
7.5 8.8 9.3 24.7 9.6 13.1 2.0 1.0 3.1 6.8
* median and IQR for logged variables
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Table 4. Pooled analysis of blood pressure and glucose outcomes with infant feeding
exposures.
Model 1 Model 2
Effect Size Effect Size
B OR 95% CI B OR 95% CI p-het
Ever breastfed
Systolic blood pressure (mmHg) -1.06 -2.17 to 0.06 -0.71 -1.84 to 0.41 0.30
Diastolic blood pressure (mmHg) -0.81 -1.73 to 0.11 -0.55 -1.49 to 0.40 0.03
Hypertension 0.78 0.59 to 1.05 0.81
0.59 to 1.11 0.56
Pre-hypertension 0.88 0.72 to 1.07 0.94
0.75 to 1.17 0.05
Glucose (mmol/l, logged, x 100) 0.26 -1.11 to 1.62 0.58 -0.86 to 2.02 0.96
Diabetes 1.26 0.63 to 2.50 1.25
0.63 to 2.51 0.97
IFG + Diabetes 0.88 0.64 to 1.21 0.92
0.67 to 1.27 0.54
Duration of breastfeeding (per category†)
Systolic blood pressure (mm Hg) 0.14 0.02 to 0.26 0.12 -0.01 to 0.24 0.28
Diastolic blood pressure (mmHg) 0.10 0.00 to 0.20 0.10 -0.01 to 0.20 0.31
Hypertension 1.01 0.98 to 1.05 1.02
0.98 to 1.05 0.92
Pre-hypertension 1.02 0.99 to 1.04 1.02
0.99 to 1.04 0.05
Glucose (mmol/l, logged, x 100) 0.07 -0.07 to 0.20 0.06 -0.09 to 0.21 0.75
Diabetes 1.05 0.98 to 1.13 1.05
0.98 to 1.13 0.80
IFG + Diabetes 1.00 0.96 to 1.04 0.99
0.96 to 1.04 0.25
Duration of breastfeeding (quadratic per category†)
Systolic blood pressure (mmHg) 0.09 0.04 to 0.14 0.08 0.03 to 0.14 0.08
Diastolic blood pressure (mmHg) 0.05 0.00 to 0.09 0.04 -0.01 to 0.08 0.05
Hypertension 1.02 1.00 to 1.03 1.02
1.00 to 1.03 0.26
Pre-hypertension 1.01 1.00 to 1.02 1.01
1.00 to 1.02 0.03
Glucose (mmol/l, logged, x 100) 0.04 -0.02 to 0.10 0.02 -0.05 to 0.08 0.99
Diabetes 1.03 1.00 to 1.06 1.03
1.00 to 1.06 0.71
IFG + Diabetes 1.02 1.00 to 1.03 1.01
1.00 to 1.03 0.89
Age at introduction of complementary foods (per category†)
Systolic blood pressure (mm Hg) 0.11 -0.37 to 0.60 0.23 -0.28 to 0.73 0.62
Diastolic blood pressure (mmHg) -0.14 -0.54 to 0.26 0.03 -0.40 to 0.45 0.74
Hypertension 1.09 0.95 to 1.25 1.12
0.97 to 1.30 0.82
Pre-hypertension 1.00 0.92 to 1.09 1.02
0.92 to 1.12 0.84
Glucose (mmol/l, logged, x 100) 0.12 -0.44 to 0.68 0.02 -0.59 to 0.62 0.70
Diabetes 1.07 0.81 to 1.40 1.01
0.76 to 1.35 0.17
IFG + Diabetes 0.99 0.87 to 1.13 0.95
0.82 to 1.09 0.28
Data were analysed using linear regression (continuous outcomes, B=regression coefficient) or
logistic regression (dichotomous outcomes, OR=odds ratio). Model 1 adjusted for subject’s age and
sex only; Model 2 further adjusted for confounders (maternal SES, education, age, smoking, race,
and rural/urban residence, and birthweight) and adult BMI and height; p-het is the test for
heterogeneity of the coefficient across studies in model 2. † categories are as defined in table 2.
There were no non-linear associations with age at introduction of complementary foods, and these
data have been omitted.
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Table 5. Pooled analysis of body composition outcomes with infant feeding exposures.
Model 1 Model 2
Effect Size Effect Size
B OR 95% CI B OR 95% CI p-het
Ever breastfed
BMI (kg/m
2
) -0.12 -0.49 to 0.25 -0.21 -0.60 to 0.17 0.33
Waist (cm) -0.62 -1.52 to 0.27 -0.67 -1.59 to 0.25 0.09
% fat -0.17 -0.82 to 0.47 -0.06 -0.70 to 0.59 0.33
Subscapular (mm, logged) -0.03 -0.09 to 0.02 -0.02 -0.07 to 0.03 0.33
Triceps (mm, logged) -0.05 -0.10 to 0.01 -0.03 -0.09 to 0.02 0.13
Obesity 0.78 0.55 to 1.11 0.77 0.54 to 1.11 0.75
Overweight/obesity 0.87 0.70 to 1.09 0.84 0.67 to 1.06 0.05
Duration of breastfeeding (per category†)
BMI (kg/m
2
) 0.03 -0.01 to 0.07 0.04 0.00 to 0.08 0.12
Waist (cm) -0.01 -0.10 to 0.08 0.05 -0.05 to 0.15 0.18
% fat -0.05 -0.12 to 0.01 0.001 -0.07 to 0.07 0.33
Subscapular (mm, logged) -0.009 -0.014 to -0.003 -0.002 -0.008 to 0.003 0.67
Triceps (mm, logged) -0.011 -0.017 to -0.006 -0.004 -0.01 to 0.002 0.65
Obesity 1.03 0.99 to 1.07 1.04 1.00 to 1.09 0.35
Overweight/obesity 1.01 0.99 to 1.04 1.02 0.99 to 1.04 0.66
Duration of breastfeeding (quadratic per category†)
BMI (kg/m
2
) 0.002 -0.015 to 0.019 0.011 -0.007 to 0.029 0.21
Waist (cm) 0.006 -0.033 to 0.046 0.030 -0.012 to 0.072 0.53
% fat -0.016 -0.044 to 0.012 0.006 -0.022 to 0.034 0.84
Subscapular (mm, logged) -0.001 -0.003 to 0.002 0.001 -0.001 to 0.003 0.68
Triceps (mm, logged) -0.001 -0.003 to 0.002 0.001 -0.001 to 0.004 0.26
Obesity 1.01 0.99 to 1.03 1.01 0.99 to 1.03 0.33
Overweight/obesity 1.00 0.99 to 1.01 1.01 0.99 to 1.02 0.33
Age at introduction of complementary foods (per category†)
BMI (kg/m
2
) -0.25 -0.41 to -0.10 -0.23 -0.40 to -0.06 0.74
Waist (cm) -0.70 -1.08 to -0.33 -0.58 -0.97 to -0.18 0.40
% body fat -0.31 -0.56 to -0.06 -0.19 -0.44 to 0.07 0.84
Subscapular (mm, logged) -0.05 -0.07 to -0.02 -0.03 -0.05 to -0.01 0.38
Triceps (mm, logged) -0.03 -0.06 to -0.01 -0.01 -0.03 to 0.02 0.55
Obesity 0.90 0.77 to 1.06 0.91 0.77 to 1.08 0.84
Overweight/obesity 0.88 0.80 to 0.97 0.88 0.80 to 0.98 0.60
Data were analysed using linear regression (continuous outcomes, B=regression coefficient) or
logistic regression (dichotomous outcomes, OR=odds ratio). Model 1 adjusted for subject’s age and
sex only; Model 2 further adjusted for confounders (maternal SES, education, age, smoking, race,
and rural/urban residence, and birthweight) and adult height; p-het is the test for heterogeneity of
the coefficient of model 2 across studies. † categories are as defined in table 2. There were no non-
linear associations with age at introduction of complementary foods, and these data have been
omitted.
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Figure 1 Associations of duration of breastfeeding with systolic blood pressure in the four cohorts
with available data, and in the pooled data
96
100
104
108
112
116
120
0 None <1 <3 <6 <9 <12 <18 <24 24+
≤
≤≤
≤1≤
≤≤
≤3≤
≤≤
≤6≤
≤≤
≤9≤
≤≤
≤12 ≤
≤≤
≤18 ≤
≤≤
≤24
Duration of Breast Feeding (Months)
Systolic Blood Pressure (mm Hg)
Mean (95% CI)
Brazil
96
100
104
108
112
116
120
0 None <1 <3 <6 <9 <12 <18 <24 24+
≤
≤≤
≤1≤
≤≤
≤3≤
≤≤
≤6≤
≤≤
≤9≤
≤≤
≤12 ≤
≤≤
≤18 ≤
≤≤
≤24
Duration of Breast Feeding (Months)
Systolic Blood Pressure (mm Hg)
Mean (95% CI)
South Africa
96
100
104
108
112
116
120
0 None <1 <3 <6 <9 <12 <18 <24 24+
≤
≤≤
≤1≤
≤≤
≤3≤
≤≤
≤6≤
≤≤
≤9≤
≤≤
≤12 ≤
≤≤
≤18 ≤
≤≤
≤24
Duration of Breast Feeding (Months)
Systolic Blood Pressure (mm Hg)
Mean (95% CI)
Guatemala
96
100
104
108
112
116
120
0 None <1 <3 <6 <9 <12 <18 <24 24+
≤
≤≤
≤1≤
≤≤
≤3≤
≤≤
≤6≤
≤≤
≤9≤
≤≤
≤12 ≤
≤≤
≤18 ≤
≤≤
≤24
Duration of Breast Feeding (Months)
Systolic Blood Pressure (mm Hg)
Mean (95% CI)
Philippines
96
100
104
108
112
116
120
0 None <1 <3 <6 <9 <12 <18 <24 24+≤
≤≤
≤1≤
≤≤
≤3≤
≤≤
≤6≤
≤≤
≤9≤
≤≤
≤12 ≤
≤≤
≤18 ≤
≤≤
≤24
Duration of Breast Feeding (Months)
Systolic Blood Pressure (mm Hg)
Mean (95% CI)
Pooled
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Figure 2 Associations of age of introduction of complementary foods with adult waist
circumference (a and b), and subscapular skinfold measurement (c and d) (fully adjusted models)
in the four cohorts with available data separately and pooled
(a) Waist circumference (b) Waist circumference (pooled data)
(c) Subscapular skinfold (d) Subscapular skinfold (pooled data)
Waist circumference (cm)
Mean (95% CI)
60
65
70
75
80
85
90
95
Pooled
Age at introduction of complementary foods (Months)
≤3≤6≤9≤12 ≤18 18+
Subscapular skinfold thickness (mm)
Geometric mean (95% CI)
0
5
10
15
20
25
30
Pooled
Age at introduction of complementary foods (Months)
≤3≤6≤9≤12 ≤18 18+
Age at introduction of complementary foods (Months)
Waist circumference (cm)
Mean (95% CI)
60
65
70
75
80
85
90
95
Brazil
Philippines
South Africa
India
≤3≤6≤9≤12 ≤18 18+
0
5
10
15
20
25
30
Brazil
Philippines
India
Subscapular skinfold thickness (mm)
Geometric mean (95% CI)
Age at introduction of complementary foods (Months)
≤3≤6≤9≤12 ≤18 18+
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Additional online material Table A Infant feeding patterns and socio-economic status at birth
Brazil
Guatemala
India
Philippines
South Africa
N
1
880
2
2181
3
846
4
267
5
250
1
253
2
249
3
231
4
228
5
205
1
31
2
161
3
334
4
755
5
245
1
467
2
355
3
410
4
420
5
396
1
423
2
325
3
432
4
291
5
149
Ever breastfed
Yes 90 92 93 93 97
100 100 100 98 100
100 100 99 100 100
99 98 97 93 88
96 96 95 93 93
No 10 8 7 7 3
0 0 0 2 0
0 0 1 0 0
1 2 3 7 12
4 4 5 7 7
N 4280
696
1448
2038
1600
p hetero 0.002
0.06
0.1
<0.001
0.3
p linear
<0.001
0.2
0.3
<0.001
0.05
Duration of breastfeeding (months)
None 10 8 7 7 3
0 0 0 2 0
No data
1 2 3 7 12
5 4 5 8 8
0.01-1.00 25 24 23 15 22
0 0 0 0 1
3 3 4 7 13
8 6 5 10 8
1.01-3.00 28 30 34 33 23
1 0 0 0 1
4 4 4 7 9
10 13 17 15 22
3.01-6.00 11 14 16 15 21
1 2 2 0 3
4 4 6 10 9
9 8 12 10 13
6.01-9.00 6 6 6 13 15
5 7 8 4 3
3 5 7 5 7
4 7 6 8 14
9.01-12.00 2 4 3 5 7
6 7 8 10 7
6 7 9 9 9
7 8 6 10 9
12.01-18.00 5 4 4 5 4
35 41 50 38 27
35 30 28 24 20
15 13 16 12 8
18.01-24.00 1 1 1 1 1
37 28 24 30 30
27 24 23 21 14
12 17 13 9 4
>24.00 11 9 7 7 5
15 16 8 16 28
16 21 16 11 9
29 24 21 18 15
N 4280
638
2038
1419
p hetero <0.001
0.01
<0.001
<0.001
p linear 0.6
1.0
<0.001
<0.001
Age at introduction of complementary foods (months)
0-3.00 61 69 74 79 82
No data
0 0 0 0 0
4 3 5 9 9
58 62 62 55 47
3.01-6.00 33 30 24 21 17
0 0 0 1 3
81 84 84 79 81
38 32 35 42 50
6.01-9.00 4 2 2 0 0
0 2 6 11 8
14 13 11 12 9
3 5 3 2 4
9.01-12.00 1 0 0 0 0
33 47 43 40 45
0 0 1 1 1
1 1 0 1 0
12.01-18.00 0 0 0 0 0
58 34 38 37 33
0 0 0 0 0
0 0 0 0 0
>18.00 0 0 0 0 0
8 17 13 11 10
0 0 0 0 0
0 0 0 0 0
N 4125
602
1995
1581
P hetero <0.001
0.2
0.001
0.06
P linear <0.001
0.008
<0.001
0.4
Data presented are column percentages. Socio-economic status at birth is categorised into five groups from least (1) to most (5) advantaged using the original scoring system
in each cohort. P hetero is the p value derived from a Chi square test, and p linear from a Chi square test for linear by linear association.
Page 37 of 49
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Additional online material Table B Infant feeding patterns and maternal education status (years of schooling)
Brazil Guatemala
India
Philippines
South Africa
Ever breastfed
Mean (SD)
N
Mean (SD)
N
Mean (SD)
N
Mean (SD)
N
Mean (SD)
N
Yes 6.6 (4.2) 3959
1.3 (1.5) 734
12.6 (2.9) 1446
7.3 (3.6) 1934
10.0 (2.5) 1513
No 5.6 (3.6) 336
1.5 (0.7) 2
12.5 (2.1) 2
10.2 (4.0) 104
9.8 (2.4) 80
ALL 6.5 (4.1) 4295
1.31 (1.5) 736
12.6 (2.9) 1448
7.4 (3.7) 2038
10.0 (2.5) 1593
p <0.001 0.8
1.0
<0.001
0.7
Duration of breastfeeding (months)
None 5.6 (3.6) 336 1.5 (0.7) 2
No data
10.2 (4.0) 104
9.8 (2.4) 80
0.01-1.00 6.3 (3.8) 995 0.5 (0.7) 2
10.0 (4.0) 120
10.0 (2.2) 103
1.01-3.00 6.5 (3.9) 1281
1.5 (2.1) 2
9.7 (3.8) 113
10.2 (2.3) 207
3.01-6.00 7.2 (4.2) 621 2.8 (1.9) 12
9.2 (3.7) 134
10.0 (2.6) 145
6.01-9.00 7.9 (5.2) 289 1.4 (1.4) 38
8.6 (3.6) 106
10.2 (2.2) 94
9.01-12.00 7.5 (4.8) 164 1.3 (1.6) 59
7.5 (3.4) 163
9.8 (2.7) 108
12.01-18.00 6.6 (4.9) 175 1.2 (1.4) 255
6.9 (3.2) 563
10.3 (2.3) 194
18.01-24.00 6.2 (4.1) 55 1.2 (1.5) 197
6.3 (3.2) 440
10.1 (2.3) 170
>24.00 5.2 (3.7) 379
1.2 (1.4) 105
5.9 (3.3) 295
9.4 (2.7) 314
ALL 6.5 (4.1) 4395
1.2 (1.5) 672
7.4 (3.7) 2038
9.9 (2.5) 1415
p hetero <0.001
0.06
<0.001
0.001
p linear 0.6
0.08
<0.001
0.02
Age at introduction of complementary foods (months)
0-3.00 6.8 (4.1) 2872
No data
- 0 8.3 (4.2) 117
9.9 (2.5) 918
3.01-6.00 6.0 (4.0) 1165
14.3 (2.0) 6 7.5 (3.7) 1630
10.1 (2.3) 590
6.01-9.00 4.2 (3.2) 80
13.2 (1.8) 50 6.1 (3.2) 238
9.9 (2.1) 53
9.01-12.00 5.6 (3.9) 22
12.7 (2.8) 254 6.0 (3.3) 10
8.7 (3.8) 12
12.01-18.00 - 0
12.6 (2.8) 220 - 0
12.0 (-) 1
>18.00 - 0
12.5 (3.1) 72 - 0
12.0 (-) 1
ALL 6.5 (4.1) 4139
12.7 (2.8) 602 7.4 (3.7) 1995
10.0 (2.4) 1575
p hetero <0.001
0.3 <0.001
0.2
p linear <0.001
0.09 <0.001
0.4
Data presented are means years of schooling. P hetero is the p value derived from a one way analysis of variance and plinear from a one way analysis of variance test for linear
trend.
Page 38 of 49
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Additional online material Table C Infant feeding patterns and maternal age
Brazil Guatemala
India
Philippines
South Africa
Ever breastfed
Mean (SD)
N Mean (SD)
N
Mean (SD)
N
Mean (SD)
N
Mean (SD)
N
Yes 26.0 (6.1) 3964
27.9 (7.1) 739
No data
26.5 (6.0) 1934
25.6 (6.1) 1518
No 26.6 (6.9) 336 33.3 (5.9) 2
28.7 (6.1) 104
25.1 (6.2) 81
ALL 26.0 (6.2) 4300
27.9 (7.1) 741
26.6 (6.0) 2038
25.6 (6.1) 1599
p 0.07 0.3
<0.001
0.4
Duration of breastfeeding (months)
None 26.6 (6.9) 336 33.3 (5.9) 2
No data
28.7 (6.1) 104
25.1 (6.2) 81
0.01-1.00 25.3 (5.9) 997 29.1 (9.7) 2
27.2 (5.6) 120
26.1 (6.2) 103
1.01-3.00 25.6 (5.9) 1282
21.0 (2.4) 2
25.5 (5.6) 113
26.0 (6.1) 207
3.01-6.00 26.2 (6.0) 621 27.3 (7.0) 12
26.2 (5.6) 134
26.1 (6.3) 145
6.01-9.00 26.5 (5.9) 290 26.7 (6.4) 39
25.9 (5.9) 106
25.9 (5.9) 94
9.01-12.00 26.6 (6.5) 164 26.3 (7.6) 60
24.4 (5.3) 163
25.7 (6.4) 110
12.01-18.00 26.7 (6.4) 176 26.1 (6.7) 258
25.7 (5.6) 563
24.2 (5.2) 194
18.01-24.00 27.0 (6.4) 55 29.4 (6.5) 197
26.8 (5.9) 440
24.5 (5.8) 170
>24.00 27.7 (6.7) 379
31.0 (7.9) 105
29.4 (6.7) 295
26.1 (6.6) 314
ALL 26.0 (6.2) 4300
27.9 (7.1) 677
26.6 (6.0) 2038
25.5 (6.1) 1418
p hetero
p linear
Age at introduction of complementary foods (months)
0-3.00 26.2 (6.2) 2874
No data
No data 26.8 (6.5) 117
25.2 (6.0) 921
3.01-6.00 25.9 (6.2) 1167
26.4 (5.9) 1630
26.1 (6.2) 592
6.01-9.00 25.3 (6.5) 81
27.7 (6.4) 238
26.8 (6.0) 53
9.01-12.00 24.9 (6.1) 22
30.5 (8.3) 10
22.8 (7.3) 12
12.01-18.00 - 0
- 0
20.0 (-) 1
>18.00 - 0
- 0
26.0 (-) 1
ALL 26.1 (6.2) 4144
26.6 (6.0) 1995
25.6 (6.1) 1580
p hetero 0.2
0.004 0.02
p linear 0.04
0.009
0.03
Data presented are mean maternal age in years. P hetero is the p value derived from a one way analysis of variance and p linear from a one way analysis of variance test for linear
trend.
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Additional online material Table D Infant feeding patterns and maternal smoking in
pregnancy
Brazil
Philippines
South Africa
Non-
smoker
N=2880
Smoker
N=1566
Non-
smoker
N=1777
Smoker
N=271
Non-
smoker
N=912
Smoker
N=55
Ever breastfed
N=4300
N=2038
N=947
Yes 92 93 95 96 96 85
No 8 7 5 4 4 15
p for difference
non-smokers v smokers
0.5 0.3 <0.001
Duration of breastfeeding
(months)
N=4300 N=2038 N=787
None 8 7 5 4 4 17
0.01-1.00 21 27 6 2 9 13
1.01-3.00 28 33 6 3 15 33
3.01-6.00 15 14 7 3 11 15
6.01-9.00 7 6 6 3 6 2
9.01-12.00 4 3 8 6 7 10
12.01-18.00 5 3 28 27 14 0
18.01-24.00 2 1 21 28 13 0
>24.00 10 7 13 24 22 10
p hetero <0.001 <0.001 <0.001
p linear
<0.001 <0.001 <0.001
Age at introduction of
complementary foods (months)
N=4144 N=1995 N=930
0-3.00 70 68 6 6 58 42
3.01-6.00 27 30 83 76 38 54
6.01-9.00 2 2 11 18 3 4
9.01-12.00 1 0 1 0 1 0
12.01-18.00 0 0 0 0 0 0
>18.00 0 0 0 0 0 0
p hetero 0.3 0.01 0.2
p linear
0.5 0.07 0.1
Data presented are column percentages. No data on maternal smoking available from India or Guatemala. Phetero and
plinear are derived from logistic regression analysis.
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Additional online material Table E Infant feeding patterns and maternal race/skin colour (Brazil and South Africa only)
BRAZIL SOUTH AFRICA
Black
N=655
White
N=3162
Asian
N=146
Mixed
N=229
Black
N=1382
White
N=37
Asian
N=24
Mixed
N=177
Ever breastfed
Yes 94
(591)
92
(2827)
88
(120)
91
(205)
96
(1308)
86
(32) 87
(20) 91
(159)
No 6
(38) 8
(241) 12
(17) 9
(21) 4
(58) 14
(5) 13
(3) 9
(15)
p hetero 0.06
0.002
Duration of breastfeeding (months)
None 6
(38) 8
(241) 12
(17) 9
(21) 5
(58) 15
(5) 16
(3) 9
(15)
0.01-1.00 18
(111)
24
(748) 23
(31) 24
(55) 6
(76) 12
(4) 16
(3) 12
(20)
1.01-3.00 27
(168)
30
(931) 28
(38) 28
(63) 12
(147) 21
(7) 32
(6) 29
(47)
3.01-6.00 14
(87) 15
(445) 15
(21) 14
(31) 9
(109) 15
(5) 16
(3) 17
(28)
6.01-9.00 7
(44) 7
(210) 5
(7) 6
(13) 6
(77) 15
(5) 11
(2) 6
(10)
9.01-12.00 5
(31) 4
(115) 4
(5) 2
(5) 8
(94) 18
(6) 0
(0) 6
(10)
12.01-18.00 7
(47) 3
(107) 4
(5) 4
(9) 16
(189) 0
(0) 5
(1) 2
(4)
18.01-24.00 2
(13) 1
(37) 1
(1) 1
(2) 14
(164) 0
(0) 5
(1) 3
(5)
>24.00 14
(90) 8
(234) 9
(12) 12
(27) 24
(290) 3
(1) 0
(0) 15
(24)
p hetero <0.001
<0.001
Age at introduction of complementary foods (months)
0-3.00 62
(373)
71
(2114)
69
(91) 64
(138)
61
(825) 39
(14) 25
(5) 46
(78)
3.01-6.00 34
(206)
27
(790) 27
(35) 33
(72) 35
(475) 56
(20) 65
(13) 50
(84)
6.01-9.00 3
(21) 1
(44) 3
(4) 2
(5) 3
(43) 6
(2) 10
(2) 4
(6)
9.01-12.00 1
(6) 0
(12) 1
(1) 0
(1) 1
(11) 0
(0) 0
(0) 1
(1)
p hetero <0.001
0.006
Data presented are column percentages (N). Phetero values are derived from logistic regression analysis.
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Additional online material Table F Infant feeding patterns and urbanicity index (Philippines)
Mean (SD)
N
Ever breastfed
Yes 29.2 (12.8) 1934
No 34.8 (12.0) 104
ALL 29.5 (12.8) 2038
p <0.001
Duration of breastfeeding (months)
None 34.8 (12.0) 104
0.01-1.00 34.6 (10.9) 120
1.01-3.00 31.7 (11.4) 113
3.01-6.00 33.5 (12.1) 134
6.01-9.00 32.8 (11.9) 106
9.01-12.00 30.2 (12.4) 163
12.01-18.00 27.8 (12.6) 563
18.01-24.00 28.0 (13.2) 440
>24.00 27.0 (13.3) 295
ALL 29.5 (12.8) 2038
p hetero <0.001
p linear <0.001
Age at introduction of complementary foods (months)
0-3.00 34.4 (12.0) 117
3.01-6.00 29.5 (12.8) 1630
6.01-9.00 26.7 (12.6) 238
9.01-12.00 30.5 (14.2) 10
ALL 29.5 (12.8) 1995
p hetero <0.001
p linear <0.001
Data presented are mean urbanicity index. Phetero values are derived from one way analysis of variance and plinear from
one way analysis of variance tests for linear trend.
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Additional online material Table G Infant feeding patterns and birth weight
Brazil
Guatemala
India
Philippines
South Africa
Ever breastfed
Mean (SD)
N
Mean (SD) N
Mean (SD)
N
Mean (SD)
N
Mean (SD)
N
Yes 3.24 (0.50)
3963
3.05 (0.47) 580
2.85 (0.41)
1314
3.02 (0.41) 1903
3.08 (0.49) 1515
No 3.08 (0.67)
336
2.84 (0.22) 2
2.70 (0.31)
2
2.97 (0.51) 104
2.82 (0.71) 81
ALL 3.23 (0.52)
4299
3.05 (0.47) 582
2.85 (0.41)
1316
3.01 (0.42) 2007
3.06 (0.51) 1596
p <0.001
0.5
0.5
0.4
<0.001
Duration of breastfeeding (months)
None 3.08 (0.67)
336
2.84 (0.22) 2
No data
2.97 (0.51) 104
2.82 (0.71)
81
0.01-1.00 3.19 (0.53)
997
- 0
3.03 (0.49) 119
3.11 (0.51)
103
1.01-3.00 3.24 (0.50)
1281
3.13 (0.53) 2
2.92 (0.44) 112
3.08 (0.55)
205
3.01-6.00 3.24 (0.48)
621
2.96 (0.46) 10
2.97 (0.44) 133
3.06 (0.52)
145
6.01-9.00 3.32 (0.47)
290
3.02 (0.54) 32
3.03 (0.42) 106
3.09 (0.52)
94
9.01-12.00 3.30 (0.47)
164
3.09 (0.42) 51
2.99 (0.41) 162
3.05 (0.47)
110
12.01-18.00 3.30 (0.49)
176
3.03 (0.46) 193
3.01 (0.39) 555
3.09 (0.46)
192
18.01-24.00 3.38 (0.51)
55
3.05 (0.46) 162
3.03 (0.39) 429
3.09 (0.46)
170
>24.00 3.28 (0.51)
379
3.02 (0.49) 81
3.03 (0.44) 287
2.06 (0.48)
315
ALL 3.23 (0.52)
4299
3.04 (0.46 533
3.01 (0.42) 2007
3.06 (0.51)
1415
p hetero 0.001
0.9
0.6
0.007
p linear <0.001
1.0
0.07
0.1
Age at introduction of complementary foods (months)
0-3.00 3.25 (0.52)
2873
No data
- 0
2.99 (0.42) 115
3.07 (0.51)
921
3.01-6.00 3.21 (0.54)
1167
2.81 (0.39)
6
3.01 (0.42) 1605
3.05 (0.52)
589
6.01-9.00 3.10 (0.51)
81
2.95 (0.44)
45
3.00 (0.41) 234
3.17 (0.43)
53
9.01-12.00 3.15 (0.52)
22
2.94 (0.42)
235
2.80 (0.39) 10
2.89 (0.39)
12
12.01-18.00 - 0
2.81 (0.42)
197
- 0
3.24 (-) 1
>18.00 - 0
2.75 (0.42)
63
- 0
3.51 (-) 1
ALL 3.23 (0.52)
4143
2.87 (0.43)
546
3.01 (0.42) 1964
3.07 (0.51)
1577
p hetero 0.4
0.3
0.3
0.3
p linear 0.006
0.001
0.6
1.0
Data presented are mean birth weight in kg. Phetero values are derived from one way analysis of variance and plinear from one way analysis of variance tests for linear trend
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Additional online material Table H Infant feeding patterns and weight at age two years
Brazil
Guatemala
India
Philippines
South Africa
Ever breastfed
Mean (SD) N
Mean (SD) N
Mean (SD) N
Mean (SD)
N
Mean (SD) N
Yes 11.13 (1.61) 3757
9.69 (1.16) 544
10.08 (1.28)
1368
9.78 (1.14) 1835
11.40 (1.67) 810
No 11.00 (1.58) 316
9.51 (-) 1
10.80 (0.45)
2
10.15 (1.33)
95
11.49 (1.38) 45
ALL 11.12 (1.60) 4073
9.69 (1.16) 545
10.08 (1.27)
1370
9.80 (1.15) 1930
11.41 (1.65) 855
p
Duration of breastfeeding (months)
None 11.00 (1.58) 316
7.51 (-) 1
No data
10.15 (1.33)
95
11.49 (1.38)
45
0.01-1.00 11.17 (1.60) 929
9.90 (-) 1
10.32 (1.49)
98
11.90 (1.79)
57
1.01-3.00 11.14 (1.60) 1226
- 0
9.97 (1.35)
97
11.27 (1.67)
110
3.01-6.00 11.23 (1.57) 591
10.38 (1.75)
5
9.91 (1.28)
118
11.34 (1.65)
76
6.01-9.00 11.29 (1.67) 275
9.41 (1.25) 16
9.78 (1.19)
100
11.44 (1.61)
52
9.01-12.00 11.06 (1.73) 155
9.79 (1.15) 30
9.79 (1.16)
153
11.97 (1.83)
59
12.01-18.00 11.15 (1.73) 169
9.85 (1.13) 226
9.73 (1.10)
547
11.40 (1.58)
125
18.01-24.00 11.24 (1.53) 54
9.48 (1.16) 168
9.75 (1.00)
427
11.23 (1.66)
107
>24.00 10.68 (1.49) 358
9.64 (1.13) 97
9.61 (1.07)
295
11.26 (1.68)
193
ALL 11.12 (1.60) 4073
9.68 (1.16) 544
9.80 (1.15)
1930
11.41 (1.67)
824
p hetero <0.001
0.02
0.4
0.07
p linear 0.002
0.1
<0.001
0.1
Age at introduction of complementary foods (months)
0-3.00 11.23 (1.59) 2825
No data
- 0
9.95 (1.26)
111
11.43 (1.66)
512
3.01-6.00 10.91 (1.60) 1147
10.78 (1.31)
5
9.83 (1.15)
1573
11.35 (1.61)
312
6.01-9.00 10.15 (1.58) 78
10.73 (1.15)
49
9.59 (1.12)
229
11.64 (2.10)
23
9.01-12.00 10.76 (1.19) 21
10.31 (1.19)
245
9.01 (1.41)
9
11.28 (1.78)
6
12.01-18.00 - 0
9.91 (1.21) 217
- 0
- 0
>18.00 - 0
9.64 (1.34) 71
- 0
10.00 (-) 1
ALL 11.12 (1.60) 4071
10.12 (1.25)
587
9.80 (1.15)
1922
11.41 (1.65)
854
p hetero 0.02
0.9
0.4
0.7
p linear <0.001
<0.001
<0.001
0.7
Data are mean weight in kg. Phetero values are derived from one way analysis of variance and plinear from one way analysis of variance tests for linear trend
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Additional online material Figure J: Forest plots showing associations in each cohort between (a) duration of breastfeeding and (b) age
of introduction of complementary foods and SYSTOLIC BLOOD PRESSURE
 
 
 
 
 
 
 
 
 
-3 -2 -1 0 1 2 3
a) Duration of breastfeeding
Brazil, F
India, F
Philippines, F
South Africa, F
Brazil, M
India, M
Philippines, M
South Africa, M
Guatemala, F
Guatemala, M
All Studies Pooled
Systolic blood pressure mmHg per category (95% CI)
 
 
 
 
 
 
 
 
 
-3 -2 -1 0 1 2 3
b) Age of introduction of complementary foods
Brazil, F
India, F
Philippines, F
South Africa, F
Brazil, M
India, M
Philippines, M
South Africa, M
Guatemala, F
Guatemala, M
All Studies Pooled
Systolic blood pressure mmHg per category (95% CI)
Analyses adjusted locally for mother’s education, socio-economic status, smoking, age, race, urban/rural status, subject’s age and birthweight
M = males
F = females
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Additional online material Figure K: Forest plots showing associations in each cohort between (a) duration of breastfeeding and (b) age
of introduction of complementary foods and PLASMA GLUCOSE
 
 
 
 
 
 
 
 
 
-0.05 -0.04 -0.03 -0.02 -0.01 0.00 0.01 0.02 0.03 0.04 0.05
a) Duration of breastfeeding
Brazil, F
India, F
Philippines, F
South Africa, F
Brazil, M
India, M
Philippines, M
South Africa, M
Guatemala, F
Guatemala, M
All Studies Pooled
Glucose per category (95% CI)
 
 
 
 
 
 
 
 
 
-0.05 -0.04 -0.03 -0.02 -0.01 0.00 0.01 0.02 0.03 0.04 0.05
b) Age of introduction of complementary foods
Brazil, F
India, F
Philippines, F
South Africa, F
Brazil, M
India, M
Philippines, M
South Africa, M
Guatemala, F
Guatemala, M
All Studies Pooled
Glucose per category (95% CI)
Analyses adjusted locally for mother’s education, socio-economic status, smoking, age, race, urban/rural status, subject’s age and birthweight
M = males
F = females
Page 46 of 49
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Additional online material Figure L: Forest plots showing associations in each cohort between (a) duration of breastfeeding and (b) age
of introduction of complementary foods and BODY MASS INDEX
 
 
 
 
 
 
 
 
 
-1.4 -1.2 -1.0 -0.8 -0.6 -0 .4 -0.2 0.0 0.2 0.4 0.6 0.8
a) Duration of breastfeeding
Brazil, F
India, F
Philippines, F
South Africa, F
Brazil, M
India, M
Philippines, M
South Africa, M
Guatemala, F
Guatemala, M
All Studies Pooled
BMI kg/m per category
2
 
 
 
 
 
 
 
 
 
-1.4 -1.2 -1.0 -0.8 -0.6 -0 .4 -0.2 0.0 0.2 0.4 0.6 0.8
b) Age of introduction of complementary foods
Brazil, F
India, F
Philippines, F
South Africa, F
Brazil, M
India, M
Philippines, M
South Africa, M
Guatemala, F
Guatemala, M
All Studies Pooled
BMI kg/m per category
2
Analyses adjusted locally for mother’s education, socio-economic status, smoking, age, race, urban/rural status, subject’s age and birthweight
M = males
F = females
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Additional online material Figure M: Forest plots showing associations in each cohort between (a) duration of breastfeeding and (b) age
of introduction of complementary foods and WAIST CIRCUMFERENCE
 
 
 
 
 
 
 
 
 
-3.5 -3.0 -2.5 -2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5
a) Duration of breastfeeding
Brazil, F
India, F
Philippines, F
South Africa, F
Brazil, M
India, M
Philippines, M
South Africa, M
Guatemala, F
Guatemala, M
All Studies Pooled
Waist circumference cm per category
 
 
 
 
 
 
 
 
 
-3.5 -3.0 -2 .5 -2.0 -1.5 -1.0 -0.5 0.0 0 .5 1.0 1.5
b) Age of introduction of complementary foods
Brazil, F
India, F
Philippines, F
South Africa, F
Brazil, M
India, M
Philippines, M
South Africa, M
Guatemala, F
Guatemala, M
All Studies Pooled
Waist circumference cm per category
Analyses adjusted locally for mother’s education, socio-economic status, smoking, age, race, urban/rural status, subject’s age and birthweight
M = males
F = females
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Additional online material Figure N: Forest plots showing associations in each cohort between (a) duration of breastfeeding and (b) age
of introduction of complementary foods and SUBSCAPULAR SKINFOLD
 
 
 
 
 
 
-0.10 -0.08 -0.06 -0.04 -0.02 0.00 0.02 0.04 0.06 0.08 0.10
a) Duration of breastfeeding
Brazil, F
India, F
Philippines, F
South Africa, F
Brazil, M
India, M
Philippines, M
South Africa, M
Guatemala, F
Guatemala, M
All Studies Pooled
Subscapular skinfold log (thickness) per group
 
 
 
 
 
 
-0.10 -0.08 -0.06 -0.04 -0.02 0.00 0.02 0.04 0.06 0.08 0.10
b) Age of introduction of complementary foods
Brazil, F
India, F
Philippines, F
South Africa, F
Brazil, M
India, M
Philippines, M
South Africa, M
Guatemala, F
Guatemala, M
All Studies Pooled
Subscapular skinfold log (thickness) per group
Analyses adjusted locally for mother’s education, socio-economic status, smoking, age, race, urban/rural status, subject’s age and birthweight
M = males
F = females
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