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September 2016, Volume 66, Issue 9

Post Delivery Management

Breastfeeding for diabetes prevention

Authors: Resham Raj Poudel  ( Department of Medicine, Western Reserve Health Education, Youngstown, OH, USA. )
Dina Shrestha  ( Department of Endocrinology, Norvic Hospital, Kathmandu, Nepal. )


Breastfeeding has been consistently observed to improve metabolism in mothers and their offspring. Apart from mother child bonding and nutritional benefits; it is associated with a decreased risk of acquiring metabolic syndrome and type 2 diabetes mellitus (T2DM) in mothers, obesity and type 1 diabetes mellitus (T1DM) in their children. Early initiation and exclusive breastfeeding should therefore be highly encouraged and strongly supported.
Keywords: Breastfeeding, Diabetes, Metabolic syndrome, Obesity.

Breastfeeding is a divine physiology at the inception of life outside the mother\\\'s womb, the benefits of which cannot be overstated. Diabetes is a common problem worldwide and frequently becomes an issue in relation to breastfeeding. There are undoubtedly multiple benefits of breastfeeding; for instance, nursing mothers have better glucose control and lowered insulin requirements and breastfed babies are less likely to develop obesity and diabetes in future.1-3 Breastfeeding has also been associated with a reduced risk of developing metabolic syndrome in women with gestational diabetes mellitus (GDM),4 and the risk of their offspring becoming overweight or obese.5 Apart from metabolic issues surrounding lactation and glucose control, there also exist in the context of diabetes, various bio-psychosocial challenges to breastfeeding which require a holistic approach.6

Risk of Diabetes Post-Partum
Prevention of diabetes or Impaired Glucose Tolerance (IGT) is of paramount importance. It is valuable to identify who is at high risk of developing diabetes postpartum. Mothers who are overweight, have a positive family history, poor physical activity and nutrition and who used medications to control GDM during pregnancy are at greater risk of developing diabetes later.7,8 While Insulin regulates initiation and maintenance of lactation  and diabetes appears to slow milk production in the early days after delivery, overweight mothers are more unsuccessful with breastfeeding compared to women of normal weight.9,10 Failure of breast milk will necessitate infant formula feeding, in which the milk protein  is associated with the risk of developing obesity and both type 1 and 2 diabetes in the child.11-13

Breastfeeding and glucose regulation
GDM mothers, particularly who are obese or required insulin for treatment during pregnancy tend to have problems with  breast feeding initiation and require earlier weaning.14,15 Breast feeding can improve metabolic function by various mechanisms. Lactogenesis requires glucose uptake, uses non-insulin mediated pathway, attenuates hyperinsulinaemia and promotes lipid utilization. Prolactin increases beta cell proliferation, beta cell mass and expression of menin. Lactation promotes energy expenditure, emotional well being and reduces stress.16,17 In GDM mothers, glucose tolerance improves with breastfeeding, evidenced by drop in glucose levels during  Oral Glucose Tolerance Test (OGTT) following breastfeeding.18 A study of more than 150 000 nurses in the USA has shown that each year of lifetime breastfeeding lowers a woman\\\'s risk of diabetes by 15% which lasts for up to 15 years after the woman\\\'s last childbirth.2,19 In a recent study in South China, breastfeeding for longer than 6 months was inversely associated with metabolic syndrome in children.20

Status of breastfeeding
Cultural norms surrounding breastfeeding have changed dramatically over the past century. Breastfeeding initiation fell from 70% in the early 1990s to 22% in 1972; again the rates have risen to 77% in 2010. Although more mothers initiate breastfeeding, they do not continue as long as they desire. 21 While physiological factors like suckling response, large breasts and nursery admissions separating neonate and  mother delay breastfeeding initiation, 16 the psycho-social and ethno-cultural barriers should also be considered. In South Asian regions, women who must return to work to support their families struggle to maintain their milk supply. Due to lack of knowledge, fear of transmission of diabetes to the child and personal reasons women choose to bottle feed with formula milk completely.

Management approach
The management approach for diabetes prevention through breastfeeding essentially centers on encouraging and supporting early initiation and exclusive breastfeeding in all mothers, particularly with GDM or those with high risk profile. Health education about diabetes and counseling the benefits and anticipated barriers to breastfeeding to increase the knowledge, attitude and practice (KAP) should begin in the antenatal period; and rigorously discussed by the end of third trimester to explore, discuss and dispel the doubts and myths. 6 Maternal knowledge about infant health benefits, and comfort with breastfeeding in social settings is directly related to intentions to breastfeed; prenatal interventions to address these issues should increase exclusive breastfeeding intention and duration.22 Mass awareness programs can also be conducted in occasions like World Breastfeeding Week, August 1-7.
Integrated care should ensure care of mother and child, lactation and endocrinology support as needed. Obstetricians should assist mothers to make an informed decision, offer anticipatory guidance, support lactation, evaluate and treat possible complications.21 Proper breast examination should be ensured and mothers should be assured of adequate breastfeeding  by providing knowledge on information like adequate maternal- infant interaction during feeding, drip milk from contralateral breast during feeding, baby satisfaction/adequate sleep, urine void, weight gain, etc.6,23 Lifestyle modification, medical nutrition therapy, screening for complications, and overall aspect of comprehensive diabetes care should be followed in all GDM mothers. Drug interactions should be kept in mind in relation to lactation. In women requiring drugs for control, insulin remains the safest option during lactation while metformin and glibenclamide are possible alternatives.24,25
Babies who are born to GDM or diabetic mothers may have fluctuating blood glucose levels and are susceptible to hypoglycaemia after birth as they continue to produce excess insulin but no longer receive a steady supply of glucose from the mother. Careful monitoring of the baby\\\'s blood glucose and frequent breastfeeding are therefore very important.2 Baby-friendly policies should be practiced and breast feeding should be initiated as soon as possible, expressed breastmilk (EBM) should be provided to neonates who are admitted in nursery. Early expression and feeding helps to ensure adequacy of lactation and prevention of breast engorgement.6

Breastfeeding has multiple benefits including the mother-child bond, vital child nutrition and several beneficial metabolic effects in both mother and child. In the context of diabetes, breastfeeding mothers have improved glucose tolerance achieved through energy expenditure, emotional well being and reduced stress, which lowers a woman\\\'s risk of diabetes. Children who are early and exclusive breastfeed are less likely to suffer from obesity and diabetes in the future. Breast feeding should be encouraged, supported and promoted strongly in all women, particularly those with GDM in order to improve long term health outcomes. It is imperative to know that there are physical, physiological, psycho-social and ethno-cultural barriers to breastfeeding. The GDM care team, including obstetricians, endocrinologists and dieticians should be aware of barriers and misconceptions related to breastfeeding, and work closely with mothers to encourage breastfeeding.

1. Pereira PF, Alfenas Rde C, Araújo RM. Does breastfeeding influence the risk of developing diabetes mellitus in children? A review of current evidence. J Pediatr (Rio J) 2014; 90: 7-15.
2. Stuebe AM. Breastfeeding and diabetes - benefits and special needs. Diabetes Voice 2007; 52: 26-9.
3. Victora CG, Bahl R, Barros AJ, Franca GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016; 387: 475-90.
4. Gunderson EP, Jacobs DR Jr, Chiang V, Lewis CE, Feng J, Quesenberry CP Jr, et al. Duration of lactation and incidence of the metabolic syndrome in women of reproductive age according to gestational diabetes mellitus status: a 20-Year prospective study in CARDIA (coronary artery risk development in young adults). Diabetes 2010; 59: 495-504.
5. Feig DS, Lipscombe LL, Tomlinson G, Blumer I. Breastfeeding predicts the risk of childhood obesity in a multi-ethnic cohort of women with diabetes. J Matern Fetal Neonatal Med 2011; 24: 511-5.
6. Kalra B, Gupta Y, Kalra S. Breast feeding: preventive therapy for type 2 diabetes. J Pak Med Assoc 2015; 65: 1134-6.
7. Shields L, Tsay GS. Editors, California Diabetes and Pregnancy Program Sweet Success Guidelines for Care. Developed with California Department of Public Health; Maternal Child and Adolescent Health Division; revised edition, September 2015.
8. Kitzmiller JL, Dang-Kilduff L, Taslimi MM. Gestational diabetes after delivery. Diabetes Care 2007; 30: 225-35.
9. Miyake A, Tahara M, Koike K, Tanizawa O. Decrease in neonatal suckled milk volume in diabetic women. Eur J Obstet Gynecol Reprod Biol 1989; 33: 49-53.
10. Hilson JA, Rasmussen KM, Kjolhede CL. Maternal obesity and breast-feeding success in a rural population of white women. Am J Clin Nutr 199;66:1371-8. (Erratum in: Am J Clin Nutr 1998;67:494.)
11. Peng H, Hagopian W. Environmental factors in the development of type 1 diabetes. Rev EndocrMetabDisord 2006; 3: 149-62.
12. Pettitt DJ, Forman MR, Hanson RL, Knowler WC, Bennett PH. Breastfeeding and incidence of non-insulin-dependent diabetes mellitus in Pima Indians. Lancet 1997; 350: 166-8.
13. Owen CG, Martin RM, Whincup PH, Smith GD, Cook DG. Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. Am J ClinNutr 2006; 84: 1043-54.
14. Amir LH, Donath S. A systematic review of maternal obesity and breastfeeding intention, initiation and duration. BMC Pregnancy Childbirth 2007; 7: 9.
15. Finkelstein SA, Keely E, Feig DS, Tu X, Yasseen AS 3rd, Walker M. Breastfeeding in women with diabetes: lower rates despite greater rewards. A population-based study. Diabet Med 2013; 30: 1094-101.
16. Much D, Beyerlein A, Roßbauer M, Hummel S, Ziegler AG. Beneficial effects of breastfeeding in women with gestational diabetes mellitus. MolMetab 2014; 3: 284-92.
17. Gunderson EP. Impact of breastfeeding on maternal metabolism: implications for women with gestational diabetes. CurrDiab Rep 2014; 14: 460.
18. Gunderson EP, Crites Y, Chiang V, Walton D, Azevedo RA, Fox G, et al. Influence of breastfeeding during the postpartum oral glucose tolerance test on plasma glucose and insulin. ObstetGynecol 2012; 120: 136-43.
19. Stuebe AM, Rich-Edwards JW, Willett WC, Manson JE, Michels KB. Duration of lactation and incidence of type 2 diabetes. JAMA 2005; 294: 2601-10.
20. Wang J, Zhu Y, Cai L, Jing J, Chen Y, Mai J, et al. Metabolic syndrome and its associated early-life factors in children and adolescents: a cross-sectional study in Guangzhou, China. Public Health Nutr 2016; 19: 1147-54.
21. Stuebe AM. Enabling women to achieve their breastfeeding goals. Obstet Gynecol 2014; 123: 643-52.
22. Stuebe AM, Bonuck K. What predicts intent to breastfeed exclusively? Breastfeeding knowledge, attitudes, and beliefs in a diverse urban population. Breastfeed Med 2011;4:413-20.
23. Zhang K, Tang L, Wang H, Qiu L, Binns CW, Lee AH. Why do mothers of young infants choose to formula feed in china? Perceptions of mothers and hospital staff. Int J Environ Res Public Health 2015; 12: 4520-32.
24. Blumer I, Hadar E, Hadden DR, Jovanovic L, Mestman JH, Murad MH, et al. Diabetes and pregnancy: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 2013; 98: 4227-49.
25. National Collaborating Centre for Women\\\'s and Children\\\'s Health. Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period. London: National Institute for Health and Care Excellence (NICE); 2015.
26. World Health Organization. Early initiation of breastfeeding. Available from: /en/. (accessed on 16 May 2015).

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