Does Extended Bottle-Feeding Really Cause Obesity?

Obesity Campaign Poster

Obesity Campaign Poster (Photo credit: Pressbound)

At 21 months, Maya still really likes hitting the bottle. It’s a ritual — the first bottle of the morning — and a request as soon as I get home from work. She sits on my lap, we cuddle, and she relaxes a bit, her body getting softer and less tense. In the evenings, I don’t give her much milk because it will ruin her dinner. We both know it’s just the pose that matters, and the snuggles that are part of that nice, quiet pause.

So of course I was immediately concerned and even a bit perturbed when my pediatrician rather abruptly told me at our last visit to stop using bottles “cold turkey” because their use is linked to obesity. Her less-than-insightful suggestion was to just get rid of all our bottles at once, and thereby make it physically impossible for Maya to keep using one. At the time, I should have asked her if she wanted to come visit for that little period of self-inflicted hell, even if just to explain to my daughter that we are only depriving her of this small comfort in order to make sure she won’t eventually become overweight.

Regardless of her apparent cluelessness about the importance of easing children into changes in their lives, I had to take seriously the problem she raised about bottles. So I went and read what I could about the study linking bottle usage to obesity (the actual text of the study is $31, and IMHO, not such a good investment).

The study, from the Journal of Pediatrics in May of last year, made headlines at the time that carried its message, including articles titled like this one: “To Avoid Adult Obesity Stop Bottle-Feeding at 18 Months,” from Medical News Today, which intoned darkly:

If you want to reduce your baby’s chances of becoming an obese adult you should not continue bottle-feeding him/her beyond 12 to 18 months.

Who wants a fat kid, really? Or this one, from U.S. News, “Prolonged Bottle Feeding Boosts Kids’ Obesity Risk,” which begins:

Nearly one-quarter of 2-year-old bottle feeders were obese at age 5, researchers say.

Well, I suppose that’s clear enough. But what did the research really say? Here’s more detail from the abstract:

Data from the Early Childhood Longitudinal Study, Birth Cohort were analyzed for 6750 US children born in 2001. The outcome was obesity (body mass index ≥95th percentile) at 5.5 years, and the exposure was parental report of the child using a bottle at 24 months. The prevalence of obesity at 5.5 years was 17.6%, and 22.3% of children were using a bottle at 24 months. The prevalence of obesity at 5.5 years was 22.9% (95% CI, 19.4% to 26.4%) in children who at 24 months were using a bottle and was 16.1% (95% CI, 14.9% to 17.3%) in children who were not.

Prolonged bottle use was associated with an increased risk of obesity at 5.5 years (OR, 1.33; 95% CI, 1.05 to 1.68) after controlling for potential confounding variables (sociodemographic characteristics, maternal obesity, maternal smoking, breastfeeding, age of introduction of solid foods, screen-viewing time, and the child’s weight status at birth and at 9 months of age). [Emphasis added.]

I’m struck by several things right off the bat. First, although nearly 23 percent of bottle-feeders were obese at the age of 5 1/2, 16 percent of the rest of the population (i.e., not bottle users) also were, which is only a 7 point difference (though it’s true that the association appears to hold at this level of the analysis).

Second, the sample size is on the small side in terms of who’s left — i.e., 22 percent of the sample used a bottle, 23 percent of whom ended up overweight. That’s a total of 341 kids. If we subtract out the 16 percent that is the general rate of obesity in the remaining population, we’re down to 55 kids whose habits and body weight are driving the conclusions (because they make up that 7-percent spread). The authors say that is a statistically significant number, though, so let’s look at their assumptions more closely.

They used a data set with limited inputs, to be sure. The first glaring omission is that the study did not account for what was in the bottles. Apple juice, for example, does not fill the stomach the way that milk does, and it creates a taste for sugary drinks in children, making it easy to consume to excess. It also contains a significant number of calories (117 per cup).

Whole milk, on the other hand, may be higher in calories, but offers a host of essential fats, vitamins and calcium. It is harder (though certainly not impossible) to over-consume because it is both filling and satisfying. Water, obviously, has no calories.

Formula, much of which is loaded with sugars that stimulate appetite, unsurprisingly is also linked in previous studies to obesity. Researchers here indicate they controlled for breastfeeding as a variable. But the formula versus breastfeeding research is complicated by studies that show bottle-fed infants gain more weight even if the bottles contain breastmilk, meaning that merely controlling for breastfeeding may not be enough.

Given that children are frequently given juices (or even worse beverages like Kool-Aid) to drink, and the small number of families whose habits are driving the conclusions, this seems like an important caveat to the findings, and one that was notably missing from the official conclusion or from the reported coverage of the study.

Instead, the authors publicly suggest the opposite, as here, where one of them claims that the study accounted for “feeding practices during infancy.” Um, I don’t think so. The two variables “age of introduction of solid foods,” and “breastfeeding” are certainly tangentially related to overall infant feeding habits (and perhaps, health), but when a study is attempting to measure the impact of bottle-feeding, controlling for the contents of that bottle strike me, at least, as one of the more important variables to be included in the equation. After all, what a child is actually consuming has just got to be more important than whether it’s being delivered by bottle or cup.

In USA Today’s piece on the article, another expert is quoted on the need to cease bottle use:

“Drinking your calories may not be as filling as eating them,” says Jennifer Shu, a pediatrician in Atlanta and the editor of HealthyChildren.org, a consumer website of the pediatrics academy. “That’s where the obesity problem comes in. It’s so easy to drink the calories, but people often are still going to eat the same amount of food.”

This argument seemed reasonable to me at first glance, but actually doesn’t really hold up. Certainly, the regular visits I made to Jamba Juice during law school likely explain why my exercise regimen at the time yielded disappointingly paltry results. Yet I don’t observe that Maya eats the same amount of food if she is full from a bottle — in fact, I worry that milk will displace other calories because she won’t be hungry, and so we limit the amounts she can drink around meals.

And all this likely misses the point. Above, Shu appears to suggest that children will, in a sense, over-drink (or over-eat because they drank too much). But so long as what children are drinking is good for them, and they are drinking and eating solid foods in the right balance, it seems to me that we wouldn’t want them to drink less. In other words, if the issue is amount, what should it matter if the drink comes from a bottle or cup? Again, parental monitoring of what is consumed, and how much, should matter far more.

Two mice; the mouse on the left has more fat s...

Two mice; the mouse on the left has more fat stores than the mouse on the right. (Photo credit: Wikipedia)

Second, the study variables omit consideration of the kind of bottle being used, whether glass or plastic. Before you think I’ve gone off the deep-end on this one, consider that studies have shown that Bisphenol-A (BPA) likely plays a significant role in obesity, both by making our bodies produce insulin as though we are consuming twice the calories we actually are, and by helping to flip a genetic switch that predisposes us to be fat.

The study’s data-set spans from 2001 to 2006, a period in which most parents were unaware of the pernicious BPA-in-baby-bottles issue and most bottles still had BPA in them, and in which plastic bottles were the norm, as they still are today. It would need far more study, of course, but in my view it’s at least possible that this is yet another instance of a simplistic analysis of behavioral factors that leaves the possibility of harmful chemical influences utterly undiagnosed.

Third, the authors’ recommendations fail to account for countervailing values in child development that may lead some families and children to benefit from extended bottle use, at least as part of their repertoire. Here’s how one of them breezily put it in an article on the study:

Rachel Gooze [] notes that weaning children from the bottle by the time they are 1 year of age is unlikely to cause harm and may prevent obesity. The authors suggest that pediatricians and other health professionals work with parents to find acceptable solutions for stopping bottle use at the child’s first birthday.

Yet research unequivocally shows that strong bonding with caregivers and relaxation (i.e., low anxiety) is essential to healthy brain development, particularly in young children ages 0 to 3 years. While extended use of a bottle is certainly not an essential part of creating these bonds and a relaxing atmosphere, the act of feeding a child is intrinsically a nurturing moment, and so it may not be irrelevant either. The researchers should have at least considered the possible downsides here.

For our family, Maya never breastfed (which is another story entirely), and so our bonding over a bottle has replaced a rather fundamental missing piece. I’m not eager to let this go based on one study showing she could, maybe, have a slightly greater chance of being obese four years from now, especially given the care and intention I take with her overall diet and the monitoring we do generally of her health, including her weight.

Obesity Campaign Poster

Obesity Campaign Poster (Photo credit: Pressbound)

For example, back on what goes into the bottle (and the baby), Maya almost never has juice, or really concentrated sugar of any kind, including the supposedly “kid-friendly” (non)foods: fruit leather, sweetened yogurt or those mushy fruit slurries in suck-down containers. (I’ll write a post on the re-joined debate over sugar and it’s impact on the body soon.)

If continuing to use a bottle appeared to be causing cavities or hampering her speech development, that would be another issue entirely, and is a legitimate concern raised by dentists (those sugary beverages again) and speech pathologists. In Maya’s case, she now has (I would guess) about 300 words and more every day. She’s also never been very interested in a pacifier or thumb-sucking, either of which can also be a speech development blocker. Moreover, she eats a wide variety of fruits, proteins and vegetables, uses both sippy cups and regular cups, and is learning to use a straw, pursuant to the advice of speech experts.

The bottle is merely a respite from these other ways for her to drink, and I assume will drop away sometime when she’s moved beyond the need for that to be our daily form of checking in. If not, we’ll ease it out of use and replace it with another important bonding ritual we can invent.

In the end, I’m unconvinced by this study, and disappointed that both my pediatrician and the mainstream press appear to have taken its limited data and recommendations as gospel. Clinical advice from most doctors rarely seems to take account of the havoc that would be wreaked on families’ emotional lives by following their rigid approach. And the discourse around the obesity issue has reached such a fever pitch that, as parents, it seems we’re now in a position, essentially, to be bossed around by experts on “slim” evidence indeed.

I hope that parents think through the issue for themselves before feeling guilted into suddenly dropping the bottle, at least based only on this latest — and in my view rather dubious — pronouncement.

###

How does your family come down on this issue? Am I just making up excuses because I don’t want to face the music (or really, screaming)?

Did I miss something important about the study or its implications? Or do you agree with me that this is just another in a too-long line of simplistic anti-obesity messages that fail to grapple with the real issues?

Are We Done Mommy-Bashing Yet?

The now-notorious Time Magazine cover image of a woman breastfeeding her three-year-old son was accompanied by the obnoxious question “Are You Mom Enough?” I immediately recognized the tactic as identical to the New York Times’ similar pseudo-rhetorical question atop an article on my efforts on toxics, called “Is it Safe to Play Yet?”

Of course, these kinds of questions are not really questions. Instead, they are snark where journalism should be.

Obviously, I take the toxics question more seriously than the Times’ Home section. We should also try to figure out the issues, and challenges, posed by “attachment parenting” – not as a catty lifestyle question or a sneer at “natural” moms – but as a serious inquiry: what kind of parental attention do children really need to thrive? And what actually works for women and families, given these needs?

There has been a predictable media and commentariat kerfuffle about the Time cover, including some terrific responses, like the one from Lisa Belkin, that pointedly refuse to sit in judgment of other moms. And some have raised the issue of this young child’s privacy and exploitation by the magazine in pursuit of sales.

In addition to the annoying headline, the photo itself is a cheap shot, substituting the intimacy of breastfeeding for a defiantly sexy image with an unmistakable Oedipal subtext. In the wake of the much-hyped release of Elisabeth Badinter’s attack on attachment parenting, The Conflict, it does appear that there may be a staged effort to transmute the “War on Women” meme that is so devastating to (mostly male) conservatives into a messy girl-fight. (“No fighting In the Mommy War Room!”)

We shouldn’t let them get away with it, and largely, we’re not. But there’s more to the discussion than simply not taking the bait. When I actually read the article associated with the sensationalized cover, I almost yawned.

The underlying story is, essentially, an arch take-down of Dr. Sears, accompanied by a tiny side-box in the print version that pronounces a few of what it calls the key tenants of attachment parenting either “true” or “untrue” – based on “the science.” For good measure, Time also threw in a short oped from a comically self-caricatured father smugly touting the benefits of being a “detachment” (read: self-indulgent) dad.

While the profile notes Dr. Sear’s extensive empire of endorsements, it disappointingly fails to take him to task for endorsing total crap, like these freeze-dried sugar pellets posing as “baby-friendly health-food” yogurt blobs. Far more importantly, while it mentions in passing his aversion to formula, strollers and cribs, it doesn’t take such subjects seriously enough to explain what, exactly, parents might usefully think about with regard to these topics. (On a single subject, the on-line, but not print, magazine does look at the “cry-it-out” issue with more seriousness, which I appreciated.)

If Time was actually practicing an act of journalism, it might have explored the research on brain development and maternal physiology that leads to infant-mother bonding and growth, or the structural tensions between the expectation that women work after having children and the alleged consensus that the benefits of breastfeeding are clear.

Instead, the editors chose to feature a mother who is actually a fashion model as an example of the sheer, unmitigated glamour of breastfeeding, and to offer up lame anecdotes like the fact that Dr. Sears and his wife “subsidized” the staying-at-home of his children’s families (hey, those yogurt blobs pay well, I’m sure).

Those of us without endorsement machines for parents have to deal with the real options for families, and it’s not a pretty picture. Structural supports for women’s choices and the choices of families – on everything from breastfeeding to maternity leave to flexible working arrangements to childcare and preschool – are largely missing, meaning that for most families, rearranging their lives around children requires extraordinary effort, exhaustion, financial and career sacrifice and general making-do.

The article did describe Dr. Sears’ evident frustration with the perception that his advice is for women to stay home (though much in his own attachment parenting literature either subtly or not-so-subtly does suggest that, as the piece points out). Generally speaking, one would think this kind of discussion would benefit from some consideration of what women actually want to do with their lives.

For some, certainly, working in the home is the most fulfilling way to raise their family, and to fully embrace its inherent comedy. In contrast, for others like me, being at home, alone, every day, with a toddler, would lead almost certainly to madness, resentment and despair, in that order, and in fairly short order.

In either circumstance, as I’ve suggested previously, it would be idiotic to think that moms, like other humans, don’t suffer ambivalence, regret and grass-is-greener syndrome.

And while it is true that not all parents are equally gifted at the exacting performance that is parenting, anyone engaged at this level with the niceties of how best to do the job is really Not Part of the Problem. So this sort of discussion of whys and wherefores should be a judgment-free zone, a convo among friends over a coffee-flavored beverage, like in those soft-focus Taster’s Choice ads.

As a Natural-Parenting inclined mom with a generally gimlet, skeptical eye, I’ve had occasion to closely examine many of the tenets of attachment and “natural” parenting.

So I will gamely, even perhaps foolishly, propose that I will do Time magazine’s job over the next little while, by examining, each in turn, a set of propositions related to attachment and natural parenting, including the following sizzling-hot subjects:

  1. Toddlers – Are there brains in there?
  2. Mother’s intuitionBasic biology or bunk?
  3. Natural childbirth – Is it for everyone (but me)?
  4. Breastfeeding – Are boobies really better than that magic powder?
  5. Co-sleeping – Do babies always have to kick your face in the night?
  6. Baby wearing – Are strollers Satan spawn?

Ok, the question part is most unserious. But I will try to tackle some of these subjects – not from a place of asking ridiculous non-questions about parenting adequacy or the evil nature of some choices – but as a chance to reflect upon my own efforts seeking to understand and grapple with these topics.

And I would love to hear your thoughts in the comments about your own experiences, questions and conclusions concerning what was right for your family.

If you have topics to add, please drop me a line – maybe you’d even want to write a piece or two for the series. (Please! How about: Cloth diapers: Are they really full of poop? Annie, I’m lookin’ at you.)

Just Those Silly Women, At It Again (Responding to Badinter)

The Women Fighting for the Breeches, by John S...

The Women Fighting for the Breeches, by John Smith (died 1743). National Portrait Gallery, London. (Photo credit: Wikipedia)

Saturday’s Wall Street Journal books page included a breathtakingly vicious attack on moms and families that practice more natural approaches to parenting, in the form of a book review for French writer Elisabeth Badinter’s new hatchet job on modern feminism called “The Conflict: How Modern Motherhood Undermines the Status of Women.”

Review author Molly Guinness nods inanely along with much of Badinter’s “argument” that, for example, “naturalism” in childbirth, breastfeeding and co-sleeping are problematic because they place too many demands on mothers and render fathers less relevant.

Notably, the book is not yet available in print in the U.S., and few facts are shared in support of this perspective. Yet Guinness deems it even more salient in the U.S., where, she alleges, without irony, that “a vast industry peddling organic baby foods and anxiety is sucking the joy out of motherhood.”

She also points out with patent admiration the “fact-y facts” that French women reportedly feel no compunction in packing their newborns off to daycare right after they’re born, and that this lack of attention to their children renders them sexier, and far more willing to recommence their wifely duties towards their, in turn, more manly, fulfilled husbands. Guinness admiringly calls this “grown-up.” Labeling co-sleeping and “militant” breastfeeding “aggressively antisexual,” she actually praises French doctors who ask new mothers the somewhat creepy question, “Is Monsieur happy?” (IMHO, the only appropriate answer: Well, I just delivered him a baby.)

(Pained side-note: if I read one more fact-deprived paean to the alleged superiority of French parenting skills, I swear that I will make protest art out of a rotten wheel of brie. And send the horrible image around on the Interwebs. I lived in France, and from my sample size of, well, me, I can say with real confidence: they’re not that great. And the men are shaped like cigarettes. And they have lots more financial support and paid leave than we do, including home visits from nurses when they are pregnant. Etc. Duh.)

In some small way, I guess it’s good news that conservatives have evidently dialed from “Freedom Fries” all the way back to just “French.” The title of the review – “Women’s War on Women – makes it all too clear why the Journal is keen to promote Badinter. It even helpfully connects the dots on the recent faux outrage from conservative circles over Hilary Rosen’s unhelpfully disparaging comment about Ann Romney’s lack of qualifications to set economic policy.

Most have moved on from this non-issue. But the Journal persists. If the “War on Women” can be recast as a girl-fight jello wrestling match, the jerky men’s club who rigged an mostly-male Congressional hearing on birth control gets off the hook. Conservatives would obviously like nothing better than for us to reimagine their latest round of attacks on women’s rights as another tragic, contested chapter in the Mommy Wars: just those silly women, at it again.

Amanda Marcotte’s insightful take-down of the right’s false sanctimony about the “hard job” of motherhood is well worth a read. As she also points out, the hypocrisy of conservatives’ reverence for stay-at-home-moms was exposed when Mitt Romney’s statements from recently as January surfaced about the need for low-income women, even those with young children at home, to work outside their home in order to get any access to basic financial supports for their family.

But Guinness is basically on board. She picks up on Badinter’s bizarre argument about contraception, which evidently, because it gives women a choice about having a child, creates an “infinite debt” and leads to “extreme mothering.” Neither of them consider that being able to choose to have a child actually means that women may want (and be able) to make space to value the process of parenting – that volition leads to the urge to be a better mother.

And there’s certainly no mention of the research on child development, summarized nicely in this book, that shows, pretty unequivocally, that healthy brain development in children ages birth to three depends upon their sense of security in the world, their social bonding with parents and caregivers, and the flow of good communication. The science backs up “attachment parenting” theories, but is in no small tension with the fact that, unless you’re the Romneys, most families need two incomes to survive. And those who do choose to stay at home pay a steep price in career advancement as well as income. Badinter thinks that decision is the problem; while I think that penalty is.

Moms who are aware of this, and have to go to work anyway, like me, probably do seek to compensate for their away time by bonding with their child in such crazy, unnatural ways as co-sleeping (like millions of families do around the world). How this harms anyone is beyond me. And rather than pitting me against my husband, he seems rather on board with the whole thing, because, you know, he’s science-y and all.

Here’s a big problem both Badinter and Guinness appear to miss: you know what really “sucks the joy” out of being a mother? Answer: An unwanted, unintended pregnancy. If contraception drives us to extreme mothering, but we’re supposed to remain always ready-to-go for the sake of our husbands, um, we’re all going to have to deal with this one, over and over again. That’s a lot of babies to kinda’ ignore.

Also on my joy-sucking list for motherhood generally: having to worry about hormone-like chemicals inside the lids of ready-to-use formula and baby food jars. Or, say, IQ- and fertility-lowering pollutants in my sofa, nursing pillow and car seat.

I would have to say that it did “suck the joy” out of motherhood, just a bit, for me to have to spend 20 hours or so over the past month researching where to get an affordable, environmentally healthy new sofa given that the chemical companies evidently have purchased a stranglehold on lawmakers in Sacramento, California, 2000 miles or so from my home. So there’s that.

Neither Badinter nor Guinness specifiy whether we’re supposed to just stop buying organic foods, or whether we should actually go ahead and affirmatively sprinkle, say, lawn pesticides, on our children’s Cheerios for added crunch. Of course, Badinter is sitting prettier on this one than we are. France actively bans many genetically modified organisms, and all of Europe has far better chemical standards than we do here. Under a law known as the REACH treaty, many chemicals must be proven to be safe before the chemical companies can put them in our bodies. (Funny story: European lawmakers were so utterly appalled by the hardball lobbying tactics used when REACH was being contemplated that they called us at Public Citizen to help them design some half-decent lobbying and ethics rules. We recognized the insidious tactics they described from, er, basically every regulatory skirmish in the U.S.) I wonder if parental outrage about potential health impacts was a factor in European governments’ choices to make any of these protective decisions…

And I can go on from here. Yes I can. For me, and I’m just speaking for me here, what really sucks the joy out of the so-important job of being a mother is the fact that we have no mandatory maternity leave in this country. That our child care tax credits are so misaligned with the actual costs of childcare it’s laughable. In fact, it’s hilarious.

Or that it took until last year for the federal government to admit breastfeeding equipment is a medical expense that we can pay for with pre-tax dollars, thereby saddling my family with thousands in higher out-of-pocket medical costs. Or, thanks to politicians like Romney, that low-income women don’t get any monetary credit at all for working to care for their children in their own home, even today.

To state the obvious: while we all now expect women to work outside the home, the actual feminist agenda of making society support the multiple roles women are supposed to play never got finished. Instead, the right pays lip service to family values while screwing women in policy and fact, and the left never seems to get around to taking our needs seriously on the big structural questions that impact women’s choices and lives.

Meanwhile, we go to work and come home, and co-sleep with our kids. And, yes, thanks, it does feel like a lot to ask of mothers to balance all these demands on their time. But asking us to care less about our children as a means to get it all done, or to stop worrying about all those pesky pesticides in our water and food, is not exactly a reliable way to restore whatever delusionally “joyful” experience of motherhood supposedly pre-dated the current moment.

Instead, we need a plan to actually support good parenting, one that really delivers for families, so that we can focus on our needs and be less stretched for time and money. Maybe, just for giggles, we should check out all the supports that they supposedly have in France.

Women engaged in the new domesticity, or good parenting, or whatever you want to call it, are not backwards looking. Instead, they’re just trying to make good on unfinished business: the core promise that feminism once made that women should be able to freely choose the values that will determine their lives.