# Presentation: 515027

## Breastfeeding and Diabetes Risk Reduction

**Breastfeeding and Diabetes Risk Reduction**

** ****Phoenix Indian Medical Center**
**Diabetes Center of Excellence**
- Charlton Wilson, MD
- Sue Murphy, MPH, RD, IBCLC

## Why Breastfeeding?

## Breastfeeding (BF) Reduces Risk of Diabetes

- Among Pima Indians being BF
-     _>_ 2 months related to less risk for developing diabetes by 40 years of age (Pettitt, 1998)

**Notes:**
Breastfeeding had been shown to contribute to less risk of DM (Pettitt, 1998)

note: - Gila River Pima Indian Community is directly south of Phoenix

## Breastfeeding may reduce risk of overweight/obesity among young children

- Almost 10,000 school age
-    children in
-    Germany
-    (Von Kries, 1999)

**Notes:**
Breastfeeding was found to be linked with reduced risk of  preschool weight problems in Europe and.....
(next slide)

note: Although association studies can not prove or disprove causality, arguments regarding this study refer to data suggesting that mother’s BMI has greater influence over weight status - higher maternal BMI leads to higher BMI of offspring. However, so far there haven’t been studies reflecting maternal weight loss from bf (and lower maternal BMI) and subsequent BMI of offspring.- sort of a circular benefit for mom and baby-child.

## ...and the risk was less with time breastfed

**Notes:**
Von Kries’ work also showed that risk was less as breastfeeding duration increased

##   Overweight/obesity prevalence among children ages 3 - 4 years by their feeding choice at 6 months of age

-   **Overweight/obesity prevalence among children ages 3 - 4 years by their feeding choice at 6 months of age**

**% overweight/obese **
**at 3-4 years of age**

**PIMC/ITCA Evaluation, 1999**

**Notes:**
Data from the Phoenix WIC program for Urban Native American families, NACHC (Native American Community Health Center) Reflects diversity of regional tribes.

This chart shows that the risk of obesity and overweight is less for children 3 - 4 years old if they are breastfed > 6 months.

Breastfeeding appears to have reduced risk of obesity/overweight for Native American Community Health Center (NACHC) WIC children

## What then?

**Notes:**
With this information  - a plan was developed.  

## Public Health Planning Model

- Baseline BF prevalence below Healthy People 2010 Goal
- Interest and value in BF high
- Multiple levels of intervention needed
- Support for initiation and maintenance needed

**Notes:**
Using the public health model (Pre-assessment, Assessment and Intervention)
Seeking cultural appropriateness/sensitivity, the following were reviewed
Recently published research of Native American populations 
Demographics 
Patient and staff focus groups 
PIMC/I.H.S systems involved with perinatal care
Our population tends to have:
Slightly younger mothers  and larger families
BF Initiation rates:   55 - 70% 
BF duration rates   20- 25% BF at 8 weeks
Strengths and barriers to breastfeeding for our families and system
Families and staff value breastfeeding
Information/support for breastfeeding not adequate (conflicting, not
                            helpful, not readily available)

## The Intervention

- Full time lactation consultant
-    (new position)
- 24 hour hot-line support
- Staff education
- Patient/family education
- Outreach/follow-up/ and surveillance
- Breastfeeding Registry established in RPMS

**Notes:**
     BF Hotline - toll free in US, staffed 24-7
     7 day per week coverage for support/referrals
     Hospital Rounds daily, post partum follow-up, home visits as needed
     Support in clinics and on OB and Peds floor – consistent availability
     BF evening class (monthly) and weekly drop-in offered
     In-services for staff about breastfeeding – short and long in-services, offered “wall to wall” whenever feasible – days, nights, weekends – best attended when food is advertised and offered and structure is informal 
     Distribution of information about breastfeeding policy and procedure 
      for employees - space, pump and time available for all employees
    Celebration of Breastfeeding events, such as  World BF week,  Open 
     house for Family Support Room (Employee pump area)
   Data Collection: Breastfeeding Registry -Modified Diabetes Registry:
  monitor babies’ first 8 weeks, and longer as available
  accumulate  moms’ and babies’ health histories 
  eventually will communicate to the providers about specific 
   mother and  baby breastfeeding progress

## Outcome

- Percentage of Mother/Infants Exclusively Breastfeeding at Birth (10/99-12/01)

**Notes:**
Good news so far  (Outcome for any breastfeeding (at initiation and at 8 weeks) is even better!)
note: !!!!!  When the most recent DM yearly report was completed, Dr Wilson noted that our obesity rate for 2-3 years has dropped each of the last 2 years. Unfortunately the obesity rates in the other age buckets has gone up... But the drop in obesity prevalence for 2-3 year olds could be due to increased bf. So we are hoping it is “that easy” - unless there is another readily available no-lose magic wand out there....  I will ask if I can send you the graphs.-- Dr. W. will be back later this afternoon - so it will probably be tomorrow before I can get them to you.

## Percentage of Mother/Infants Exclusively Breastfeeding at 8 weeks (10/99-12/01)

## Rate of Breastfeeding Cessation  8 weeks, (10/99 - 12/01)

**Notes:**
Fewer families are quitting

## Slide 13

**Notes:**
The number of calls (and minutes used ) has gone up in the last 1 1/2 years 

The cost has remained stable at about $40/month.  

20% of calls occur outside of 8 am - 5 pm M - F time frame.

## Continued surveillance
Explore missing data elements such as:
 Accomplishment of early latch – not well documented in medical records, but noted statistically to be positively related to duration
 Perceived insufficient milk supply and pain (maternal) – known to be the most universal reasons for lactation cessation 
 Issues related to mother and baby separation   (work/school) 

- Continued surveillance
- Explore missing data elements such as:
-  Accomplishment of early latch – not well documented in medical records, but noted statistically to be positively related to duration
-  Perceived insufficient milk supply and pain (maternal) – known to be the most universal reasons for lactation cessation
-  Issues related to mother and baby separation   (work/school)

- Where to now?

**Notes:**
Initiation: Continue to increase patient and community awareness of breastfeeding’s benefit for reducing diabetes risk
Support at birth to insure early latch whenever feasible  - early contact increases likelihood of successful lactation 	(AAP; Chute, G. (1992). Breastfeeding. NAACOG’s Clinical Issues in Perinatal and Women’s Health Nursing, 3 (4), 572;  Lawrence, R. (1994), Breastfeding: A Guide for the Medical Profession, Mosby-Year Book, Inc. pp. 232-233; Riordan, J and Auerbach, K. (11993). Breastfeeding and human Lactation, Boston: Jones and	 Bartlett Publishers, pp. 217-19)
Duration: more frequent follow-up within 1 week postpartum – hopefully impact pain and perceived insufficient milk supply concerns
More staff education Customize BF ed. for staff needs
Explore :
    impact of parity - PIMC data indicates that:
 Moms who with >3 children are 3 times more likely to formula feed
 As parity increases, number of weeks breastfeeding decreases
    impact of breastfeeding on:
 our populations’ illness/hospitalization rates 
 weight gain patterns as our babies grow 
  Extend Outreach:  
Continue to develop community partnerships to support BF, empower other groups to consider the possibilities

Provide one day (8 hour) it is highly portable (!)  staff training (with CEUs) - Supporting the Choice to Breastfeed.

DCOE, NIH and southern AZ tribal communities “Close to the Heart” video, pamphlet, poster and calendar completed - calendars for 2003 will be available soon, brochure will be downloadable from Office of Women’s Health (www.4women.gov) soon. Video and posters are available as requested.  (all items are free, while supplies last)

BF Promotion Group (WIC and lactation support staff from many AZ communities) will be developing a pamphlet “Easy Guide to Breastfeeding for Native Americans” - to be available via Office of Women’s Health by this Fall)

## Evaluate reasons for cessation of breastfeeding to design targeted interventionsEvaluate growth patterns and health issues associated with feeding choiceIntegrate breastfeeding support service into organizational performance improvement program

- Evaluate reasons for cessation of breastfeeding to design targeted interventionsEvaluate growth patterns and health issues associated with feeding choiceIntegrate breastfeeding support service into organizational performance improvement program

## Expand collaborative efforts	

	Share technical assistance with IHS/ Tribal/Urban programs Explore program designs specific to individual community needs
	Assist with developing policy and procedure formats for 
		establishing lactation support services		Develop problem solving network for patient/program concernsFoster support for community events such as conferences, health
		fairs, local campaignsEncourage mutually beneficial affiliations with agencies such as
	 	WIC and Healthy Mothers, Healthy Babies
	Network knowledge of continuing education opportunities 
		including supportive studying for formalized certification for
		lactation counselors Share staff in-service and class outlines and resources
	Collaborate to develop and share culturally appropriate education 	materials and promotions

- Expand collaborative efforts
- 	Share technical assistance with IHS/ Tribal/Urban programs Explore program designs specific to individual community needs
- 	Assist with developing policy and procedure formats for
- 		establishing lactation support services		Develop problem solving network for patient/program concernsFoster support for community events such as conferences, health
- 		fairs, local campaignsEncourage mutually beneficial affiliations with agencies such as
- 	 	WIC and Healthy Mothers, Healthy Babies
- 	Network knowledge of continuing education opportunities
- 		including supportive studying for formalized certification for
- 		lactation counselors Share staff in-service and class outlines and resources
- 	Collaborate to develop and share culturally appropriate education 	materials and promotions

## 	The message is hope --
				 there are ways to 				      reduce the						 risk of
					    diabetes --

					breastfeeding 
					is one of them

- 				 there are ways to 				      reduce the						 risk of
- 					    diabetes --
- 					breastfeeding
- 					is one of them

**Notes:**
Perhaps out of all of it, the most important piece is that there is hope.