Intergenerational impact of maternal obesity and postnatalfeeding practices on pediatric obesity

Amanda L Thompson

The postnatal feeding practices of obese and overweight mothers may place theirchildren at increased risk for the development of obesity through shared biology andfamily environments. This article reviews the feeding practices of obese mothers,describes the potential mechanisms linking maternal feeding behaviors to childobesity risk, and highlights the potential avenues of intervention. Strategiesimportant for improving the quality of the eating environment and preventing theintergenerational transmission of obesity include supporting breastfeeding,improving the food choices of obese women, and encouraging the development offeeding styles that are responsive to hunger and satiety cues.© 2013 International Life Sciences Institute

INTRODUCTION

With the growing prevalence of obesity worldwide, anincreasing proportion of women enter pregnancy over-weight or obese. In the United States, 35% of women overthe age of 20 are obese (body mass index [BMI] >30 kg/m2), and 64% are overweight or obese (BMI > 25 kg/m2).1

Although the national prevalence of obesity in pregnantwomen is not available, data from the Pregnancy RiskAssessment Monitoring System (PRAMS), a population-based surveillance system in 26 US states and New YorkCity, indicate that one in five women giving birth in2004–2005 was obese.2 The potential negative impact ofmaternal obesity and overweight on public health extendfrom the immediate consequences of poor birth out-comes, such as stillbirth, macrosomia, and neonatal inten-sive care unit admission, to longer-term consequences foroffspring, including obesity and chronic disease.3–5 Mater-nal obesity prior to, during, and after pregnancy increasesthe risk of pediatric obesity.3,6,7 Maternal obesity in earlypregnancy more than doubles the risk of overweight inyoung children,8 and maternal adiposity, measuredthrough mid-upper-arm circumference, is associatedwith higher fat mass in early childhood.6,9 Indeed, a familyhistory of obesity, particularly maternal obesity, is one of

the strongest risk factors for obesity at any stage in thelifecycle.10

This concordance between maternal and childobesity stems from a number of factors, including sharedgenetic risk factors,11 nutritional conditions of the intrau-terine environment,3,4,7 and shared postnatal dietary,physical, and behavioral characteristics.12–14 While therelative importance of each of these roles continues to bedebated,3,7,12 the impact of maternal obesity on childfeeding, a modifiable postnatal risk factor moderatingchild obesity risk,15 may be particularly important inshaping long-term dietary habits by influencing foodavailability, modeling eating behaviors, and shaping foodpreferences. Feeding differences between obese and non-obese mothers have generally received less attention inthe literature; however, obese mothers are less likely tobreastfeed16,17 and more likely to overfeed their childrenor provide a poor-quality diet.18 Since young childrenlearn how, what, when, and how much to eat based onfamilial, and particularly maternal, beliefs, attitudes, andpractices surrounding food and eating during the transi-tion to solid foods and family diets,19,20 children of obesemothers may be at greater risk for the developmentof obesogenic, lifelong eating practices. Thus, thisarticle reviews the infant and toddler feeding practices of

Affiliations: AL Thompson is with the Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina,USA, and the Department of Anthropology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.

Correspondence: AL Thompson, Department of Anthropology, University of North Carolina at Chapel Hill, 123 W Franklin St, CB #8120,Chapel Hill, NC 27516, USA. E-mail: althomps@email.unc.edu. Phone: +1-919-843-6255. Fax: +1-919-966-6638.

Key words: maternal feeding behaviors, obese mothers, postnatal feeding practices, pediatric obesity

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Supplement Article

doi:10.1111/nure.12054Nutrition Reviews® Vol. 71(Suppl. 1):S55–S61 S55

overweight and obese mothers (focusing on the first 2years of life where possible), discusses proposed mecha-nisms linking early feeding practices to the intergenera-tional transmission of obesity in humans and animalmodels (Figure 1), and highlights potential opportunitiesfor intervention.

MATERNAL OBESITY AND BREASTFEEDING

One aspect of early-life feeding differences between obeseand nonobese mothers that has received a great deal ofattention is breastfeeding initiation and duration. Breast-feeding initiation is consistently lower and durationconsistently shorter in overweight and obese womencompared with normal-weight women. A recent meta-analysis found that overweight and obese women were1.19–3.09 times less likely to initiate breastfeeding,16

while a population-based study of nearly 300,000 birthsin the United Kingdom found that maternal obesity wasassociated with significantly reduced odds of breastfeed-ing at hospital discharge.21 Among overweight and obesewomen who do establish breastfeeding, duration is alsoshorter. Obese women are over 50% less likely to breast-feed at 6 months compared with normal-weight women,even when adjustment is made for a number of potentialconfounders such as breastfeeding intention, age,smoking, and depression.16

Weight-related disparities in breastfeeding initiationand duration stem from a number of physiological andpsychosocial causes. Obese mothers are more likely to

experience pregnancy- and delivery-related complica-tions such as fetal macrosomia and cesarean-sectiondelivery, leading to difficulty in establishing breastfeed-ing.17 Excess adiposity prior to, during, and after preg-nancy contributes to dysregulation of the hypothalamic-pituitary-gonadal axis,22 low prolactin levels in responseto infant suckling,23 and delayed onset of milk produc-tion.24 Overweight and obese women are nearly 2.5 timesmore likely than normal-weight women to have a latearrival of milk,16 a significant risk factor for breastfeedingcessation or formula supplementation.25 Obese womenalso tend to have larger breasts, which can cause mechani-cal challenges for latching on and positioning duringfeeding and can contribute to difficulties in establishingand maintaining breastfeeding.16 Additionally, infants ofobese mothers may have a higher demand for energyintake and be less satisfied with breastmilk,26 leading toperceived milk insufficiency.27 Obese mothers are alsoless likely to seek breastfeeding support when difficultieswith milk production are encountered,27 further reducingbreastfeeding duration.

The role of physiology in limiting the breastfeedingcapabilities of obese women remains unclear since theassociation between overweight/obesity and breastfeed-ing is confounded by a number of social and psychologi-cal factors. Obesity is more common among women whohave lower socioeconomic status and depression, bothindependent risk factors for lower rates of breastfeed-ing.26,28 Adjustment for a host of potential confounders,including race/ethnicity and poverty, identified only arelatively small independent effect of maternal obesity on

ChildOverweight

/Obesity

MaternalOverweight

/Obesity

Breastfeeding Initiation andDuration

Diet PatternsSweet and Fat Preferences

Energy Intake

Feeding EnvironmentFood Responsiveness

Feeding StylesDisinhibition

Physiological limitationsLack of supportDiscomfort

Modeling, Shared geneticsAppetitive characteristics

Emotional contextResponsivenessWeight concerns

Figure 1 Maternal obesity, feeding behaviors, and child obesity risk. Reviewed literature showing feeding differencesbetween overweight/obese mothers and normal-weight mothers. Potential mechanisms linking maternal obesity to thesefeeding practices are shown along the solid-line pathways. Dashed lines indicate the potential pathways linking maternalfeeding behaviors to child overweight/obesity.

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breastfeeding duration of less than 2 weeks.29 Moreover,the association between obesity and reduced breastfeed-ing does not appear to be universal across societies,16

suggesting that the social positioning of obese womenand the stigma associated with maternal obesity are deter-minants of breastfeeding practice. A study of Americanwomen who were highly committed to breastfeeding andsupported by their partners and physicians highlightsthe strong psychosocial influence on breastfeeding.30

Despite similar intentions to breastfeed, obese mothersbreastfed for shorter durations and failed to meet theirown breastfeeding goals, a finding that was explained inpart by a lack of comfort and confidence in their bodiespostpartum.30

Regardless of its causes, reduced breastfeeding maybe an important mechanism in the intergenerationaltransmission of obesity. Although the importance ofbreastfeeding for preventing later obesity has recentlybeen called into question,31 numerous studies indicatethat breastfeeding provides weak-to-moderate protectionagainst the development of later obesity, with an overallreduction in odds ranging between 20% and 30%.32–34

Infants weaned earlier gain weight more rapidly,35 possi-bly due to higher energy intakes from formula feeding,36

impaired self-regulation,37 and earlier complementaryfeeding.38 The interaction between maternal weight statusand breastfeeding practices on child obesity has beenexamined less often, but a study of Danish infants foundthat infants of overweight women had higher weightgains, shorter durations of breastfeeding, and earlierintroduction to solid foods.35 The additive effect of mater-nal obesity and lack of breastfeeding on child overweighthas been documented in 2,636 American 2- to 14-year-old children whose mothers participated in the NationalLongitudinal Survey of Youth 1979 (NLSY79).39 Childrenwith overweight mothers who did not breastfeed had asixfold greater risk of overweight compared with thebreastfed children of normal-weight mothers.

Whether breastfeeding by obese mothers protectsagainst child obesity remains an open question. In theNLSY79, breastfeeding for at least 4 months reduced themagnitude of the risk of obesity – although obesity riskwas still higher among the children of obese mothers –indicating that breastfeeding remains protective evenwhen mothers are obese.39 This finding contrasts researchin humans and animal models documenting that mater-nal diet can alter the composition of breastmilk, poten-tially attenuating its benefits.5 Obesity-derived alterationsin fat metabolism negatively impact the triglyceride com-position of breastmilk.40,41 Breastmilk contains a higherproportion of medium-chain fatty acids when the fattyacids are produced via de novo synthesis in the breastthan when they are derived from maternal fat stores,which contribute longer-chain fatty acids (LCFAs).41

Maternal obesity and/or high-fat diets then could reducethe proportion of the more readily digested medium-chain fatty acids and increase the proportion of LCFAs.Unlike medium-chain fatty acids, LCFAs require bile fortransport across the infant intestine and, in young infantswith immature digestive systems, may not be wellabsorbed. Thus, milk with a greater proportion of LCFAscould lead to greater infant hunger, a risk factor forsupplementation with formula and/or solid food.

Along with these differences in fat content, differ-ences in the hormonal content of obese mothers’ breast-milk could play a critical role in programming the neuralcircuitry regulating appetite, energy balance, and eatingbehavior in offspring.5,42,43 In rat models, the offspring ofobese mothers fed a highly palatable diet during preg-nancy and lactation have higher levels of orexigenic pep-tides, develop hyperphagia, and have greater adiposity inadolescence and adulthood.5,7,43 While the exact mecha-nisms leading to hyperphagia have yet to be identified,elevated levels of lipids, leptin, or insulin in the plasmaand breastmilk of obese mothers have been implicated aspossible programming factors.5 Comparable studies arelacking in humans; however, measurement of infantsucking behavior indicates that exposure to maternalobesity induces changes in human infant eating behavioras well. Sucking frequency was 50% higher in 3-month-old infants born to obese mothers and predicted bodyweight at age 2 years.44 In addition to potential exposureto metabolic hormones in breastmilk, shared appetitetraits between obese mothers and their offspring may alsolink maternal obesity to infant sucking behaviors. Recentresearch in a birth cohort of twins45 found that the appe-tites of mothers and their 3-month-old infants were sig-nificantly correlated. Heritability modeling furthersuggested that shared genetics accounted for nearly 50%of the variance in appetite size. How breastfeeding maymoderate these shared propensities to influence thedevelopment of appetitive characteristics merits furtherresearch.

MATERNAL OBESITY AND CHILD DIETARY PATTERNS

While the association between maternal obesity andreduced duration of breastfeeding is well documented,few studies have examined differences in solid feedingpractices between obese and normal-weight mothers.4,41,46

This transition to solid foods, however, is particularlyimportant in the establishment of long-term eatingbehaviors.As children transition to the family diet, mater-nal diet preferences and practices exert greater influenceon the types and amounts of foods available to youngchildren, which in turn shape child preferences and con-sumption. Mothers play an important role in modelingfood choices,14,47 and their weight status affects children’s

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food preferences, perhaps even more than children’s ownweight status.48 Differences in the diets of obese mothers,who may more eat energy-dense, high-fat foods,49 there-fore, could influence both what children are fed and thelikelihood of early excess weight gain.

Few studies have directly examined the infantfeeding practices of obese mothers, but much evidencedocuments that maternal food intake is associated withchildren’s eating behaviors from a young age.50–53 Parentintake has been associated with child intake across allfood groups except sugar-sweetened beverages,54 thoughthe magnitude of this association differs across child ageand weight status, sociodemographic indicators, and race/ethnicity.50,53 Poor maternal diet quality is associated withthe early introduction and inappropriate quality of solidfoods in infants,55 and similarities in the types of foodsconsumed begin in the second year of life.53 In the limitedresearch examining the infant-feeding practices of obesemothers, obese mothers introduced solid foods soonerthan normal-weight mothers35 and provided a poorer-quality diet with higher proportions of “adult” foods totheir infants.18

These solid feeding practices could contribute tohigher energy intakes in infants and young children, arisk factor for later obesity.56 A small laboratory-basedstudy found that infants born to obese mothers con-sumed more energy and more energy as carbohydratesthan infants of normal-weight mothers and that thesehigher intakes were due to increased consumption ofsolid foods.46 More recently, 6-year-old children withobese mothers were found to consume more energyacross 3 days of weighed food records.10 These higherintakes were seen despite a lack of difference in the energydensity of selected foods, suggesting that greater intakesrather than diet choices per se were responsible for thehigher calories consumed.

Along with providing a model for diet patterns,maternal food choices shape child food preferences. Aheightened, shared preference for sweets and sugar-sweetened drinks has been identified in overweight andobese mothers and their children across a number ofsettings. Overweight mothers introduced sweets, pastries,and sugar-sweetened beverages to infants earlier thannormal-weight mothers, and infants consumed thesesweets more frequently if their mothers were overweightand ate sweets more frequently themselves.57 In alaboratory-based observational study, obese mothersand their preschool children ate more sweets thannormal-weight mothers and their children, althoughthere were no differences in consumption of other foodtypes.58 Similarly, mothers and their children share pref-erences for high-fat foods. A number of studies havedocumented that both parental preference for high-fat foods and parental adiposity are associated with

preschool children’s preferences for high-fat foods49 andthe percentage of energy consumed as fat.49,59 Such find-ings have led researchers to conclude that shared geneticpredispositions to sweeter and higher-fat foods underliethe development of obesogenic diets in obese mothersand their children.14,60 Experimental animal models,however, also show that exposure to maternal high-sugarand high-fat diets during gestation or lactation increasesoffspring preference for higher-sugar and higher-fat dietsinto adulthood in rats, sheep, and nonhuman pri-mates.12,43 Rats whose mothers were fed high-fat “junkfood” diets during pregnancy and lactation, for example,develop an exaggerated preference for fatty and/or sweetfoods compared with animals fed a control diet.42,61 Thus,both shared genetics and shared dietary exposures arelikely important in determining long-term preferences.

MATERNAL OBESITY AND CHILD FEEDING BEHAVIORS

Along with these differences in dietary patterns andintake, maternal feeding practices also shape the physicaland emotional context of eating.20,62 Mothers’ interac-tions with their children during meals, instrumental useof foods to reward or control child behavior, and feedingstyles influence children’s energy balance and eatingbehavior, and evidence suggests these feeding practicesdiffer between obese and normal-weight mothers. Obesemothers of infants and toddlers reported a lower degreeof structure during feeding, higher rates of televisionwatching and lower interaction during meals, and a lessset mealtime routine in a large, ethnically diversesample.63 Obese mothers also spent less time interactingwith their infants and less time feeding them over thecourse of a 24-h observation period in a laboratory-basedstudy.46 Since the quality of family interactions duringeating influences children’s eating practices, attitudestoward food, and assessment of satiety,20 this lack ofresponsive interactions during feeding can negativelyimpact a child’s intake of food.

Obese mothers may also model eating in response tofactors external to hunger and satiety. A recent observa-tional study64 found that mothers’ responsiveness to full-ness cues in their infants and toddlers was inverselyassociated with their own BMI. These findings suggestthat overweight or obese mothers, who may be less awareof their own internal satiety cues, may similarly not rec-ognize these cues in their infants. Obese mothers mayconsume foods for emotional reasons and, in their chil-dren, use foods instrumentally to reward or control childbehavior.65 They may also encourage eating and prompttheir children to eat more during meals.65 While relativelylittle research has focused on infants, studies show thatpreschool children with obese parents have higherresponsiveness to foods60 and exhibit greater overeating

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in response to emotional cues than children with normal-weight parents.60,66 These findings are not universal,however, and a number of studies have found no differ-ence between obese and normal-weight mothers inprompting child eating,65,67 using food as a reward or inresponse to emotional distress, or encouraging childrento eat more.58,65,68,69 Disinhibited eating, an eating stylecharacterized by the tendency to consume large amountsof palatable foods in a short time not in response to hun-ger,70 on the other hand, consistently differs betweenthe children of obese and normal-weight mothers.70–73

Although eating in the absence of hunger (EAH), abehavioral measure of disinhibited eating, has not beenstudied in infants, preschool children show differences inEAH that are associated with maternal obesity. Boys withobese mothers consumed more food in the absence ofhunger – measured as snack consumption after an adlibitum meal consumed until full – than normal-weightboys.74 These results indicate that children with obesemothers may be more responsive food availability or,alternatively, less responsive to satiety cues.

Comparison of the feeding styles of obese and non-obese mothers also indicates that the emotional contextand attitudes surrounding feeding differ by maternalweight status.65 Mothers with higher BMIs reported usingmore restrictive feeding practices and limiting the quan-tity and quality of foods provided to their toddlers; inaddition, they were observed using more pressure to getchildren to eat during mealtimes.68 Among mothers of18- to 64-month-old children, maternal BMI andmothers’ concerns about their weight were related to theuse of controlling (pressuring or restrictive) feeding prac-tices.68 Similarly, mothers of preschool children reporteda greater use of restriction when they had greater weightand eating concerns of their own,72 suggesting thatrestrictive practices are influenced by mothers’ ownstruggles with their weight and concerns about their chil-dren’s future weight struggles beginning early in life.Other studies, however, have found that higher maternalBMI73 and obesity65 were associated with lower levels ofmaternal control, so the relationship between maternalweight, weight concerns, and child feeding clearly variesacross populations of mothers and children.

Interestingly, a number of studies have found no evi-dence of an obesogenic feeding style that distinguishesobese from normal-weight mothers.65,71,75 Rather, restric-tive feeding styles may produce different growth out-comes in the children of obese mothers, who arepredisposed to excessive weight gain due to sharedgenetic and environmental influences.71 A number ofstudies have found that maternal restriction or controlduring feeding is associated with obesity in the childrenof obese but not normal-weight mothers.10,71,75,76 Further-more, restrictive feeding styles and the emotional use of

food cluster in obese mothers placing the children of suchmothers at particular risk for excess weight gain.10 Theuse of restriction by overweight mothers of 5-year-oldgirls, who themselves had greater EAH than normal-weight mothers,71 was associated with increased EAH intheir daughters from 5–9 years of age and higher BMIs at9 years of age.70 Taken together, the differential impactof feeding styles and disinhibited eating on the childrenof obese mothers indicates that maternal overweightmay provide both the predisposition and the contextfor the development of obesogenic eating behaviors inchildren.71

CONCLUSION

Increasing evidence supports an important role formaternal obesity in the development of childhood obesityand subsequent adult disease. However, critical gaps inthe literature remain. Further research is particularlyneeded to address the complementary feeding practicesof overweight and obese mothers and how these prac-tices, in conjunction with shared biology and shared psy-chosocial and physical feeding environments, may shapethe development of appetite, energy intakes, and foodpreferences during the critical periods of early infancy,the transition to solid foods, and the adoption of thefamily diet. Many of these pathways linking maternalobesity and feeding practices to child overweight are welldescribed for preschool children; yet, while receivingcomparatively less attention, differences in the early-lifefeeding practices of obese mothers may be particularlyimportant in the intergenerational transmission ofobesity.

The poorer quality of early-life diet, characterized bylow levels of breastfeeding and higher intakes of high-energy and high-fat foods, seen in the infants and youngchildren of obese mothers places them at risk for excessweight gain.38,56 Exposure to these obesogenic early dietsalso influences appetite regulation, entraining the hypo-thalamic neural circuitry that regulates appetite by induc-ing permanent changes in the complex pathways that linkthe hypothalamus, the gastrointestinal tract, and adiposetissue.77 Along with these physiological impacts, maternaldiet modeling,14 the foods available in the household,51

and the emotional climate surrounding infant feeding20

shape later responsiveness to satiety cues and food accep-tance. Obese mothers’ feeding styles may be more or lessresponsive to infant hunger and satiety cues, and, whencombined with early solid feeding and/or poor dietquality, less responsive feeding contributes to intakes inexcess of needs and “overriding” of the infant’s internalsatiety cues. Thus, early intervention is needed to stem thedevelopment of an obesogenic eating environment and toprevent early excess weight gain.

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Improving food choice and reducing caloric intakein children at risk for obesity are required for long-termchange, and, given the influence of mothers – as theprimary food providers – on their children’s diets, two-generation programs are essential.62 Results from inter-ventions targeting the overweight and obese mothers ofobese children indicate that parental role modeling ofhealthy behaviors has the greatest impact on children’seating and activity behaviors.78 Overweight and obesemothers who modify their food choices are more likely tomake comparable changes for their children, resulting inimproved toddler diets with lowered intakes of calories,fat, sugar-sweetened beverages, and fast foods.78 Further-more, studies suggest that focusing on improving food-related parenting styles, which includes encouragingmothers both to assume leadership roles in changingfeeding environments and to grant appropriate childautonomy while remaining firm and supportive, alsoresults in an improved food environment as well as lesssedentary behavior in children.62 Focusing on supportingbreastfeeding, improving the food choices of obesewomen, and encouraging the development of authorita-tive feeding styles may improve the quality of the early-life feeding environment, which is a critical step forpreventing early obesity.

Acknowledgments

Funding. The author is supported by the National Insti-tutes of Health: National Institute of Child Health andHuman Development (NIH: NICHD) (K01 HD071948-01) and thanks the Carolina Population Center (R24HD050924) for general support.

Declaration of interest. The authors have no relevantinterests to declare.

REFERENCES

1. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity amongUS adults, 1999–2008. JAMA. 2010;303:235–241.

2. Chu SY, Kim SY, Bish CL. Prepregnancy obesity prevalence in the United States,2004–2005. Matern Child Health J. 2009;13:614–620.

3. Oken E. Maternal and child obesity: the causal link. Obstet Gynecol Clin NorthAm. 2009;36:361–377, ix–x.

4. Poston L. Maternal obesity, gestational weight gain and diet as determinants ofoffspring long term health. Best Pract Res Clin Endocrinol Metab. 2012;26:627–639.

5. Rooney K, Ozanne SE. Maternal over-nutrition and offspring obesity predisposi-tion: targets for preventative interventions. Int J Obes (Lond). 2011;35:883–890.

6. Burdette HL, Whitaker RC, Hall WC, et al. Breastfeeding, introduction of comple-mentary foods, and adiposity at 5 y of age. Am J Clin Nutr. 2006;83:550–558.

7. Ruager-Martin R, Hyde MJ, Modi N. Maternal obesity and infant outcomes. EarlyHum Dev. 2010;86:715–722.

8. Strauss RS, Knight J. Influence of the home environment on the development ofobesity in children. Pediatrics. 1999;103:e85.

9. Blair NJ, Thompson JM, Black PN, et al. Risk factors for obesity in 7-year-oldEuropean children: the Auckland Birthweight Collaborative Study. Arch DisChild. 2007;92:866–871.

10. Kral TV, Rauh EM. Eating behaviors of children in the context of their familyenvironment. Physiol Behav. 2010;100:567–573.

11. Maes HH, Neale MC, Eaves LJ. Genetic and environmental factors in relative bodyweight and human adiposity. Behav Genet. 1997;27:325–351.

12. Reynolds RM. Childhood obesity: the impact of maternal obesity on childhoodobesity. In: Ovesen PG, Jensen DM, eds. Maternal Obesity and Pregnancy. Berlin:Springer-Verlag; 2012:255–270.

13. Robinson SM, Godfrey KM. Feeding practices in pregnancy and infancy: relation-ship with the development of overweight and obesity in childhood. Int J Obes(Lond). 2008;32(Suppl 6):S4–S10.

14. Scaglioni S, Arrizza C, Vecchi F, et al. Determinants of children’s eating behavior.Am J Clin Nutr. 2011;94(Suppl 6):S006–S011.

15. Thompson AL. Developmental origins of obesity: early feeding environments,infant growth, and the intestinal microbiome. Am J Hum Biol. 2012;24:350–360.

16. Amir LH, Donath S. A systematic review of maternal obesity and breastfeedingintention, initiation and duration. BMC Pregnancy Childbirth. 2007;7:9.

17. Rasmussen KM. Association of maternal obesity before conception with poorlactation performance. Annu Rev Nutr. 2007;27:103–121.

18. Robinson S, Marriott L, Poole J, et al. Dietary patterns in infancy: the importanceof maternal and family influences on feeding practice. Br J Nutr. 2007;98:1029–1037.

19. Savage JS, Fisher JO, Birch LL. Parental influence on eating behavior: conceptionto adolescence. J Law Med Ethics. 2007;35:22–34.

20. Patrick H, Nicklas TA. A review of family and social determinants of children’seating patterns and diet quality. J Am Coll Nutr. 2005;24:83–92.

21. Sebire NJ, Jolly M, Harris JP, et al. Maternal obesity and pregnancy outcome: astudy of 287,213 pregnancies in London. Int J Obes Relat Metab Disord.2001;25:1175–1182.

22. Bray GA. Obesity and reproduction. Hum Reprod. 1997;12(Suppl 1):26–32.23. Rasmussen KM, Kjolhede CL. Prepregnant overweight and obesity diminish the

prolactin response to suckling in the first week postpartum. Pediatrics.2004;113:e465–e471.

24. Chapman DJ, Perez-Escamilla R. Identification of risk factors for delayed onset oflactation. J Am Diet Assoc. 1999;99:450–454; quiz 455–456.

25. Chapman DJ, Perez-Escamilla R. Does delayed perception of the onset of lacta-tion shorten breastfeeding duration? J Hum Lact. 1999;15:107–111; quiz 137–139.

26. Oddy WH, Li J, Landsborough L, et al. The association of maternal overweightand obesity with breastfeeding duration. J Pediatr. 2006;149:185–191.

27. Mok E, Multon C, Piguel L, et al. Decreased full breastfeeding, altered practices,perceptions, and infant weight change of prepregnant obese women: a need forextra support. Pediatrics. 2008;121:e1319–e1324.

28. Hendricks K, Briefel R, Novak T, et al. Maternal and child characteristics associ-ated with infant and toddler feeding practices. J Am Diet Assoc. 2006;106(1Suppl 1):S135–S148.

29. Li R, Zhao Z, Mokdad A, et al. Prevalence of breastfeeding in the United States:the 2001 National Immunization Survey. Pediatrics. 2003;111(5 Pt 2):1198–1201.

30. Hauff LE, Demerath EW. Body image concerns and reduced breastfeeding dura-tion in primiparous overweight and obese women. Am J Hum Biol. 2012;24:339–349.

31. Casazza K, Fontaine KR, Astrup A, et al. Myths, presumptions, and facts aboutobesity. N Engl J Med. 2013;368:446–454.

32. Arenz S, Ruckerl R, Koletzko B, et al. Breast-feeding and childhood obesity – asystematic review. Int J Obes Relat Metab Disord. 2004;28:1247–1256.

33. Harder T, Bergmann R, Kallischnigg G, et al. Duration of breastfeeding and risk ofoverweight: a meta-analysis. Am J Epidemiol. 2005;162:397–403.

34. Owen CG, Martin RM, Whincup PH, et al. Effect of infant feeding on the risk ofobesity across the life course: a quantitative review of published evidence. Pedi-atrics. 2005;115:1367–1377.

35. Baker JL, Michaelsen KF, Rasmussen KM, et al. Maternal prepregnant body massindex, duration of breastfeeding, and timing of complementary food introduc-tion are associated with infant weight gain. Am J Clin Nutr. 2004;80:1579–1588.

36. Heinig MJ, Nommsen LA, Peerson JM, et al. Intake and growth of breast-fed andformula-fed infants in relation to the timing of introduction of complementaryfoods: the DARLING study. Davis Area Research on Lactation, Infant Nutrition andGrowth. Acta Paediatr. 1993;82:999–1006.

37. Bartok CJ, Ventura AK. Mechanisms underlying the association between breast-feeding and obesity. Int J Pediatr Obes. 2009;4:196–204.

38. Huh SY, Rifas-Shiman SL, Taveras EM, et al. Timing of solid food introduction andrisk of obesity in preschool-aged children. Pediatrics. 2011;127:e544–e551.

39. Li C, Kaur H, Choi WS, et al. Additive interactions of maternal prepregnancy BMIand breast-feeding on childhood overweight. Obes Res. 2005;13:362–371.

40. Finley DA, Lonnerdal B, Dewey KG, et al. Breast milk composition: fat content andfatty acid composition in vegetarians and non-vegetarians. Am J Clin Nutr.1985;41:787–800.

41. Wojcik KJ. Maternal determinants of childhood obesity: weight gain, smoking,and breastfeeding. In: Freemark M, ed. Contemporary Endocrinology: PediatricObesity: Etiology, Pathogenesis and Treatment. New York: Springer; 2010:93–102.

42. Sullivan EL, Smith MS, Grove KL. Perinatal exposure to high-fat diet programsenergy balance, metabolism and behavior in adulthood. Neuroendocrinology.2011;93:1–8.

Nutrition Reviews® Vol. 71(Suppl. 1):S55–S61S60

43. Drake AJ, Reynolds RM. Impact of maternal obesity on offspring obesity andcardiometabolic disease risk. Reproduction. 2010;140:387–398.

44. Stunkard AJ, Berkowitz RI, Schoeller D, et al. Predictors of body size in the first 2y of life: a high-risk study of human obesity. Int J Obes Relat Metab Disord.2004;28:503–513.

45. Llewellyn CH, van Jaarsveld CH, Plomin R, et al. Inherited behavioral susceptibil-ity to adiposity in infancy: a multivariate genetic analysis of appetite and weightin the Gemini birth cohort. Am J Clin Nutr. 2012;95:633–639.

46. Rising R, Lifshitz F. Relationship between maternal obesity and infant feeding-interactions. Nutr J. 2005;4:17.

47. Anzman SL, Rollins BY, Birch LL. Parental influence on children’s early eatingenvironments and obesity risk: implications for prevention. Int J Obes (Lond).2010;34:1116–1124.

48. Epstein LH, Valoski A, Wing RR, et al. Perception of eating and exercise inchildren as a function of child and parent weight status. Appetite. 1989;12:105–118.

49. Fisher JO, Birch LL. Fat preferences and fat consumption of 3- to 5-year-oldchildren are related to parental adiposity. J Am Diet Assoc. 1995;95:759–764.

50. Beydoun MA, Wang Y. Parent-child dietary intake resemblance in the UnitedStates: evidence from a large representative survey. Soc Sci Med. 2009;68:2137–2144.

51. Hart CN, Raynor HA, Jelalian E, et al. The association of maternal food intake andinfants’ and toddlers’ food intake. Child Care Health Dev. 2010;36:396–403.

52. Oliveria SA, Ellison RC, Moore LL, et al. Parent-child relationships in nutrientintake: the Framingham Children’s Study. Am J Clin Nutr. 1992;56:593–598.

53. Papas MA, Hurley KM, Quigg AM, et al. Low-income, African American adoles-cent mothers and their toddlers exhibit similar dietary variety patterns. J NutrEduc Behav. 2009;41:87–94.

54. Raynor HA, Van Walleghen EL, Osterholt KM, et al. The relationship betweenchild and parent food hedonics and parent and child food group intake in chil-dren with overweight/obesity. J Am Diet Assoc. 2011;111:425–430.

55. Lee SY, Hoerr SL, Schiffman RF. Screening for infants’ and toddlers’ dietaryquality through maternal diet. MCN Am J Matern Child Nurs. 2005;30:60–66.

56. Ong KK, Emmett PM, Noble S, et al. Dietary energy intake at the age of 4 monthspredicts postnatal weight gain and childhood body mass index. Pediatrics.2006;117:e503–e508.

57. Brekke HK, van Odijk J, Ludvigsson J. Predictors and dietary consequences offrequent intake of high-sugar, low-nutrient foods in 1-year-old children partici-pating in the ABIS study. Br J Nutr. 2007;97:176–181.

58. Lewis M, Worobey J. Mothers and toddlers lunch together. The relation betweenobserved and reported behavior. Appetite. 2011;56:732–736.

59. Nguyen VT, Larson DE, Johnson RK, et al. Fat intake and adiposity in children oflean and obese parents. Am J Clin Nutr. 1996;63:507–513.

60. Wardle J, Guthrie C, Sanderson S, et al. Food and activity preferences inchildren of lean and obese parents. Int J Obes Relat Metab Disord. 2001;25:971–977.

61. Bayol SA, Farrington SJ, Stickland NC. A maternal “junk food” diet in pregnancyand lactation promotes an exacerbated taste for “junk food” and a greater pro-pensity for obesity in rat offspring. Br J Nutr. 2007;98:843–851.

62. Golan M, Crow S. Targeting parents exclusively in the treatment of childhoodobesity: long-term results. Obes Res. 2004;12:357–361.

63. Baughcum AE, Powers SW, Johnson SB, et al. Maternal feeding practices andbeliefs and their relationships to overweight in early childhood. J Dev BehavPediatr. 2001;22:391–408.

64. Hodges EA, Johnson SL, Hughes SO, et al. Development of the responsiveness tochild feeding cues scale. Appetite. 2013;65:210–219.

65. Wardle J, Sanderson S, Guthrie CA, et al. Parental feeding style and the inter-generational transmission of obesity risk. Obes Res. 2002;10:453–462.

66. Jahnke DL, Warschburger PA. Familial transmission of eating behaviors inpreschool-aged children. Obesity (Silver Spring). 2008;16:1821–1825.

67. Lumeng JC, Burke LM. Maternal prompts to eat, child compliance, and motherand child weight status. J Pediatr. 2006;149:330–335.

68. Haycraft EL, Blissett JM. Maternal and paternal controlling feeding practices:reliability and relationships with BMI. Obesity (Silver Spring). 2008;16:1552–1558.

69. Berkowitz RI, Moore RH, Faith MS, et al. Identification of an obese eating style in4-year-old children born at high and low risk for obesity. Obesity (Silver Spring).2010;18:505–512.

70. Francis LA, Ventura AK, Marini M, et al. Parent overweight predicts daughters’increase in BMI and disinhibited overeating from 5 to 13 years. Obesity (SilverSpring). 2007;15:1544–1553.

71. Francis LA, Birch LL. Maternal weight status modulates the effects of restrictionon daughters’ eating and weight. Int J Obes (Lond). 2005;29:942–949.

72. Francis LA, Hofer SM, Birch LL. Predictors of maternal child-feeding style: mater-nal and child characteristics. Appetite. 2001;37:231–243.

73. Fisher JO, Birch LL. Restricting access to foods and children’s eating. Appetite.1999;32:405–419.

74. Faith MS, Berkowitz RI, Stallings VA, et al. Eating in the absence of hunger: agenetic marker for childhood obesity in prepubertal boys? Obesity (SilverSpring). 2006;14:131–138.

75. Powers SW, Chamberlin LA, van Schaick KB, et al. Maternal feeding strategies,child eating behaviors, and child BMI in low-income African-American pre-schoolers. Obesity (Silver Spring). 2006;14:2026–2033.

76. Faith MS, Berkowitz RI, Stallings VA, et al. Parental feeding attitudes and stylesand child body mass index: prospective analysis of a gene-environment interac-tion. Pediatrics. 2004;114:e429–e436.

77. Agostini C. Ghrelin, leptin and the neurometabolic axis of breastfed and formula-fed infants. Acta Paediatr. 2005;94:523–525.

78. Klohe-Lehman DM, Freeland-Graves J, Clarke KK, et al. Low-income, overweightand obese mothers as agents of change to improve food choices, fat habits, andphysical activity in their 1-to-3-year-old children. J Am Coll Nutr. 2007;26:196–208.

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