Breastfeeding and the Obesity Pandemic.
Breastfeeding and the Obesity Pandemic.
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母乳喂养和肥胖流行。
DOI：
10.1016/j.ajcnut.2023.04.035
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发表时间：
2023
期刊：
影响因子：
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通讯作者：
Pérez-Escamilla,Rafael
中科院分区：
文献类型：
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作者：
Pérez-Escamilla,Rafael
母亲肥胖与开始母乳喂养的可能性较低以及完全母乳喂养和纯母乳喂养的持续时间较短之间存在一致的关联[1，2]。这是引起公众健康关切的一个主要原因，因为育龄妇女继续受到肥胖症流行病的严重和不成比例的影响。据估计，到2035年，全球大部分人口（51%，或超过40亿人）将超重或肥胖[BMI（kg/m2）25]，25%的人（近20亿人）将肥胖（BMI 30）[3]。此外，到2035年，23%的成年男性（6.9亿）和27%的成年女性（8.42亿）将患有肥胖症。已经假设了四种潜在的机制来解释产妇肥胖和次优泌乳之间的关系，包括母乳产量不足的风险增加：1）与伴随慢性炎症的肥胖相关的脂肪和葡萄糖代谢变化相关的改变，2）由于乳房大而导致的机械闭锁困难，3）身体形象心理情感耻辱，可能导致妇女不打算母乳喂养或产生过量的应激激素，阻碍哺乳过程，和4）延迟开始哺乳伴随着引入泌乳前喂养，延迟开始母乳喂养和缩短任何母乳喂养和纯母乳喂养持续时间的已知风险因素[2，4 - 7]。尽管其机制尚未完全阐明，但研究继续阐明母体肥胖与次优泌乳之间关联的生物学可解释性。Keyes等人进行的一项稳健研究的结果。[8]基于在西班牙、希腊和美国进行的3项队列研究（n <$5120），在调整关键的社会经济和人口统计学混杂因素后，显示母亲孕前超重和肥胖与任何母乳喂养和纯母乳喂养持续时间较短相关。重要的是，他们发现这种关系是由更高的饮食炎症指数、C反应蛋白（仅限于母乳喂养）和剖腹产所介导的[8]。最近一项仔细进行的病例对照研究表明，分娩足月儿且产后前4周产奶量非常低的母亲（n = 23）（定义为在任何测试体重测量期间从未超过300 mL/d，相当于纯母乳喂养婴儿所需的最低预期母乳量的一半）[9]，具有显著较高的肥胖和炎症生物标志物，乳汁中长链脂肪酸（LCFA）浓度较低，与中等（n = 20）和/或足量产奶（n = 18）的女性相比，血浆和乳汁LCFA之间的关联被破坏。这些发现表明炎症破坏了正常的乳腺脂肪酸摄取[9]。令人鼓舞的是，最近的一项系统综述和荟萃分析发现，母乳喂养咨询干预对超重或肥胖妇女的母乳喂养开始和持续时间产生了积极影响[10]。根据Keyes等人的研究结果，[8]，毫不奇怪，一方面，荟萃分析结果强调自孩子出生以来迫切需要母乳喂养支持。另一方面，数据清楚地表明，为了使干预措施更具影响力，他们需要考虑潜在的代谢改变和耻辱问题，这些问题可能会对超重和肥胖妇女的哺乳过程产生负面影响。需要开发创新的、以证据为基础的方法，为婴儿提供有效的母乳喂养咨询。
There is a consistent association between maternal obesity and a lower likelihood of initiation of breastfeeding, as well as a shorter duration of total and exclusive breastfeeding [1, 2]. This is a major cause of public health concern as women of reproductive age continue to be affected strongly and disproportionately by the obesity pandemic. Globally, it is estimated that by 2035, most of the population (51%, or over 4 billion people) will be living with either overweight or obesity [BMI (in kg/m2) 25], and 25% of people (nearly 2 billion) will be obese (BMI 30)[3]. Furthermore, by 2035, 23% of adult men (690 million) and 27% of adult women (842 million) will have obesity [3]. Four potential mechanisms have been hypothesized to explain the relationship between maternal obesity and suboptimal lactation, including an increased risk of insufficient breast milk production: 1) alterations related to obesity-related fat and glucose metabolic changes accompanied by chronic inflammation, 2) mechanical latch difficulties because of large breasts, 3) body image psycho-emotional stigma that may lead women not to intend to breastfeed or to produce an excessive amount of stress hormones that hinder the lactation process, and 4) delayed onset of lactation accompanied by the introduction of prelacteal feeds, a known risk factor for delayed initiation of breastfeeding and shorter durations of any and exclusive breastfeeding [2, 4–7]. Although the mechanisms have not been fully elucidated, studies continue to shed light on the biological plausibility of the association between maternal obesity and suboptimal lactation. Findings from a robust study conducted by Keyes et al.[8] based on 3 cohort studies conducted in Spain, Greece, and the United States (n ¼ 5120) showed that maternal prepregnancy overweight and obesity were associated with shorter durations of any and exclusive breastfeeding, after adjusting for key socioeconomic and demographic confounders. Importantly, they found that this relationship was mediated by a higher dietary inflammation index, C-reactive protein (only for exlcusive breastfeeding), and cesarean-section deliveries [8]. A carefully conducted case-control study recently showed that mothers who delivered term babies and had very low milk production during the first 4 wk postpartum (n ¼ 23)(defined as never exceeding 300 mL/d during any test-weigh measurement period, which corresponds to half of the minimum expected amount of breast milk needed by an exclusively breastfed infant)[9], had significantly higher obesity and inflammatory biomarkers, lower concentrations of long-chain fatty acids (LCFAs) in milk, and disrupted association between plasma and milk LCFAs compared with women with moderate (n ¼ 20) and/or adequate amounts of milk production (n ¼ 18). These findings suggest that inflammation disrupts normal mammary gland fatty acid uptake [9]. It is encouraging that a recent systematic review and meta-analysis found positive impacts of breastfeeding counseling interventions on breastfeeding initiation and duration among women who were overweight or obese [10]. Given the findings from the study by Keyes et al.[8], it is not surprising that, on the one hand, the meta-analysis findings emphasize the strong need for breastfeeding support since the birth of the child. On the other hand, the data clearly show that for interventions to be more impactful, they will need to consider potential metabolic alterations and stigma issues that may negatively affect the lactation process among women with overweight and obesity. Innovative, evidence-based approaches need to be developed to provide effective breastfeeding counseling to …