Dietary Energy Density Is Associated with Biomarkers of Chronic Diseases-A Cross-Sectional Study of School-Aged Children in Rural Mexico.

Background: Dietary energy density (DED) is associated with chronic disease markers in adults. However, results in children are still controversial. Objective: To evaluate the DED of children and its association with obesity and biomarkers of chronic disease. Methods: In this cross-sectional study, we recruited 284 children (6-10 y) from rural Mexico. Dietary intake was assessed using three 24-h recalls. DED was calculated for "foods only" (DEDfo) and for "foods and beverages" (DEDfb). Weight, height, and body fat percent (dual-energy X-ray absorptiometry) were measured. Inflammatory cytokines, lipid profile, leptin, and insulin resistance were determined from a fasting blood sample. Results: DEDfo was 1.91 ± 0.36 kcal/g and DEDfb was 1.36 ± 0.31 kcal/g. Higher DEDfo and DEDfb were associated with higher risk to have insulin resistance [odds ratio (OR) = 3.92, 95% confidence interval (CI): 1.66, 9.22, P < 0.01; OR = 3.51, 95% CI: 1.25, 9.87, P = 0.02, respectively]. Higher DEDfo was associated with higher risk of higher leptin levels (OR = 3.17, 95% CI: 1.01, 10.23). Also, DEDfo and DEDfb were associated with higher concentrations of cholesterol (ß = 11.67, 95% CI: 1.81, 19.53, P = 0.03; and ß = 11.74, 95% CI: 2.69, 20.74 P = 0.01, respectively) and higher odds of having high insulin concentrations (OR = 2.52, 95% CI: 1.26, 5.06, P = 0.01; and OR = 2.95, 95% CI: 1.30, 6.70, P = 0.01). DEDfo and DEDfb were not associated with any measure of obesity and inflammatory cytokines in the adjusted models. Conclusions: DED was associated with higher leptin and cholesterol concentrations, and having insulin resistance, but not with any measure of obesity or inflammation. Reducing DED may reduce risk of cardiovascular disease and improve insulin sensitivity in school-aged children.

Proximity and High Density of Convenience Stores Was Associated With Obesity in Children of a Rural Community of Mexico: Using a Geographic Information System Approach.

BACKGROUND: Food environment (FE) has been linked to obesity in urban areas, but there is limited information in rural areas, particularly in developing countries, where prevalence of obesity is high. OBJECTIVE: To determine the association between FE and childhood obesity using Geographic Information Systems (GIS). METHODS: A total of 218 (8-10 years) children participated in a cross-sectional study. Weight, height, and body fat were measured. Geolocation of convenience stores (CS) and participants' households was collected, and the amount of processed food (PF) in the stores was measured. The proximity to the nearest CS and the number of CS within a 250-m buffer from each participant's household was calculated using GIS. Linear regression models between obesity measurements and FE were performed. RESULTS: The combined prevalence of overweight and obesity was 32%. A total of 91% of the children had access to a CS within 250 m. On average, 48% of the shelf-space of the CS were occupied with PF. A positive association between the density of CS with body fat % (ß = .145; 95% CI, 0.048-0.241, P = .004), abdominal fat % (ß = .206; 95% CI, 0.048-0.241, P = .003), and body mass index (BMI)-for-age z-score (BMIz; ß = .028; 95% CI, 0.005-0.062, P = .005) was found. Living closer to CS was associated with increases in body fat % (ß = -0.009; 95% CI, -0.017 to -0.001, P = 0.025), abdominal fat % (ß = -0.012; 95% CI, -0.023 to -0.001, P = 0.033), and BMIz (ß = -0.002, 95% CI, -0.004 to -0.001, P = 0.003). CONCLUSION: In a rural community in Mexico, a high density and low proximity to CS is associated with obesity in school-aged children.

Ascariasis, Amebiasis and Giardiasis in Mexican children: distribution and geographical, environmental and socioeconomic risk factors.

The aim of this study is to provide an overview of the geographical distribution of Ascariasis, Amebiasis and Giardiasis, and to identify specific geographical, socioeconomic and environmental factors that are associated with the incidence of these infections in Mexican children. We made use of publicly available data that was reported by federal organizations in Mexico for the year 2010. The contribution of geographical, socioeconomic and environmental factors to the incidence of infections was assessed by a multivariable regression model using a backwards selection procedure. A. lumbricoides incidence was associated with mean minimum temperature of the state, the state-wide rate of households without access to piped water and toilet, explaining 77% of the incidence of A. lumbricoides infections. Mean minimum precipitation in the state, the rate of households without access to a toilet, piped water and sewage system best explained (73%) the incidence of E. histolytica infections. G. lamblia infections were only explained by the latitude of the state (11%). In addition to the well-known socioeconomic factors contributing to the incidence of A. lumbricoides and E. histolytica we found that temperature and precipitation were associated with higher risk of infection.

Several problem nutrients are identified in the complementary diet of 6 to 11 month old breastfed children in Western Guatemala.

BACKGROUND AND OBJECTIVES: The failure of infants in developing countries to meet nutrient intake recommendations is well documented. The objective of this study was to assess the nutritional adequacy and identify problem nutrients of the diets of Guatemalan infants with continued breastfeeding. METHODS AND STUDY DESIGN: A single previous-day dietary recall was collected from a convenience sample of 94 mothers of infants aged 6-11 mo attending a public health clinic in the urban area of Quetzaltenango, Guatemala. Energy and nutrient content of complementary feeding (CF) and breastmilk, modelled by subtracting estimated energy intakes from CF from energy requirements, were calculated and nutrient adequacy of the diet was assessed. Nutrient densities and critical nutrient densities of CF were computed to identify "problem nutrients" and main food sources of these nutrients. RESULTS: Complementary diets were adequate for protein, but likely to be inadequate for pantothenic acid and vitamins C, A, D, E, and K, as well as calcium, iron and zinc. In the worst-case scenario, i.e. for small girls with limited energy allowances, riboflavin, niacin, vitamin B-6 and magnesium were identified as "problem nutrients" as well. Formula milk, cow milk and Incaparina® were main food sources of "problem nutrients". CONCLUSIONS: The intake of micronutrients during the first six months of the recommend CF period in Guatemala has a number of notable inadequacies, but the gaps are narrower than traditionally reported for this age group in low-income settings.

Microbiome, growth retardation and metabolism: are they related?

CONTEXT: Despite an improvement in food security and the delivery of nutritional supplements to children living in impoverished parts of the world, poor growth is still highly prevalent. Given that the microbiome is related to both nutrient absorption, as well as overweight/obesity, it may play a central role in limiting or modifying normal growth processes while contributing to chronic disease risks. OBJECTIVE: The objective of this paper is to describe normal growth processes, the role of the microbiome in supporting or disrupting normal growth processes, and its potential impact on long-term health. METHODS: A literature search of relevant human and laboratory research on growth, microbiome and the relationship between poor growth and chronic diseases was conducted. This review focuses on potential mechanisms that implicate the microbiome as a mediator of poor growth and later metabolic outcomes. In this relationship, attention was given to the potential for gastrointestinal infections to disrupt the microbiome. RESULTS: Based on the studies reviewed, it is clear that exposure to infections disturbs both intestinal functioning as well as normal growth and changes in the microbiome may influence micronutrient availability and metabolic processes. CONCLUSIONS: The microbiome may play a significant role in limiting human growth, but little is known about changes in the microbiome during periods of undernutrition. Thus, it is of great scientific and public health importance to improve the understanding of how the microbiome changes during nutrient deprivation. To best address the issue of the double burden and poor growth in low-income countries, research is warranted to advance the knowledge of the long-term role of the microbiome in the health of children exposed to undernutrition.

The stunted child with an overweight mother as a growing public health concern in resource-poor environments: a case study from Guatemala.

BACKGROUND: Overweight and obesity are emerging at alarming rates in low income women in many countries. Guatemala has the additional burden of a high prevalence of chronic under-nutrition (stunting) in children. AIM: The purpose of this paper is to explore the dual burden of infant and child (5-23 months) under-nutrition and maternal over-weight and obesity in the Western Highlands of Guatemala. SUBJECTS AND METHODS: Anthropometric measures were collected in 446 mother-infant dyads in a metropolitan population of mixed indigenous (Maya) and non-indigenous descent in the Western Highlands of Guatemala. Children were identified as stunted based on a height for age <-2 below the WHO reference median and maternal overweight/obesity defined as a BMI ≥25. Stunted children with an overweight/obese mother were compared to other children who were not stunted and/or who did not have an overweight/obese mother. RESULTS: The prevalences of stunting (38%) and maternal overweight/obesity (45%) were high, but just 17% of the mother and child pairs were dual burden. The socio-demographic characteristics of stunted children were not influenced by maternal overweight or obesity. CONCLUSION: Policies are needed to address under-nutrition as well as preventing obesity and obesity-related chronic disease risks of stunted children and their mothers.

Energy contribution from non-breastmilk items in low-income Guatemalan infants in their sixth month of life.

OBJECTIVE: To examine the nature and energy contribution of complementary feeding in breastfed infants in their sixth month of life, and the prevalence of the use of bottles as a delivery method. MATERIALS AND METHODS: We recruited 156 breastfeeding infants at a health clinic in metropolitan Quetzaltenango, Guatemala. A previous-day recall was performed. RESULTS: Sixty nine mothers (44%) reported offering items other than breastmilk. The median contribution of energy from complementary foods among infants with mixed feeding (n=66) was 197 kcal/day (interquartile range [IQR] 49-353). The median energy contribution of formula or cow's milk among consumers (n=39) was 212 kcal/day (IQR 84-394). Bottles were used on the previous day by 55 (80%) of the 69 mothers not offering exclusive breastfeeding. CONCLUSIONS: Premature introduction of non-breastmilk items is commonly practiced in feeding Guatemalan infants. Adherence to the internationally recognized guidelines for early infant feeding should be an intervention priority for this population.

Stunting at birth: recognition of early-life linear growth failure in the western highlands of Guatemala.

OBJECTIVE: Measurements of length at birth, or in the neonatal period, are challenging to obtain and often discounted for lack of validity. Hence, classical 'under-5' stunting rates have been derived from surveys on children from 6 to 59 months of age. Guatemala has a high prevalence of stunting (49.8%), but the age of onset of growth failure is not clearly defined. The objective of the study was to assess length-for-age within the first 1.5 months of life among Guatemalan infants. DESIGN: As part of a cross-sectional observational study, supine length was measured in young infants. Mothers' height was measured. Length-for-age Z-scores (HAZ) were generated and stunting was defined as HAZ <-2 using WHO growth standards. SETTING: Eight rural, indigenous Mam-Mayan villages (n 200, 100% of Mayan indigenous origin) and an urban clinic of Quetzaltenango (n 106, 27% of Mayan indigenous origin), Guatemala. SUBJECTS: Three hundred and six newborns with a median age of 19 d. RESULTS: The median rural HAZ was -1.56 and prevalence of stunting was 38%; the respective urban values were -1.41 and 25%. Linear regression revealed no relationship between infant age and HAZ (r = 0.101, r(2) = 0.010, P = 0.077). Maternal height explained 3% of the variability in HAZ (r = 0.171, r(2) = 0.029, P = 0.003). CONCLUSIONS: Stunting must be carried over from in utero growth retardation in short-stature Guatemalan mothers. As linear growth failure in this setting begins in utero, its prevention must be linked to maternal care strategies during gestation, or even before. A focus on maternal nutrition and health in an intergenerational dimension is needed to reduce its prevalence.

Height, zinc and soil-transmitted helminth infections in schoolchildren: a study in Cuba and Cambodia.

Soil-transmitted helminth (STH) infections and zinc deficiency are often found in low- and middle-income countries and are both known to affect child growth. However, studies combining data on zinc and STH are lacking. In two studies in schoolchildren in Cuba and Cambodia, we collected data on height, STH infection and zinc concentration in either plasma (Cambodia) or hair (Cuba). We analyzed whether STH and/or zinc were associated with height for age z-scores and whether STH and zinc were associated. In Cuba, STH prevalence was 8.4%; these were mainly Ascaris lumbricoides and Trichuris trichiura infections. In Cambodia, STH prevalence was 16.8%, mostly caused by hookworm. In Cuban children, STH infection had a strong association with height for age (aB-0.438, p = 0.001), while hair zinc was significantly associated with height for age only in STH uninfected children. In Cambodian children, plasma zinc was associated with height for age (aB-0.033, p = 0.029), but STH infection was not. Only in Cambodia, STH infection showed an association with zinc concentration (aB-0.233, p = 0.051). Factors influencing child growth differ between populations and may depend on prevalences of STH species and zinc deficiency. Further research is needed to elucidate these relationships and their underlying mechanisms.

Energy contribution from non-breastmilk items in low-income Guatemalan infants in their sixth month of life / Contribución de energía de fuentes diferentes a la leche materna en infantes de seis meses de edad de bajos recursos en Guatemala

Objective. To examine the nature and energy contribution of complementary feeding in breastfed infants in their sixth month of life, and the prevalence of the use of bottles as a delivery method. Materials and methods. We recruited 156 breastfeeding infants at a health clinic in metropolitan Quetzaltenango, Guatemala. A previous-day recall was performed. Results. Sixty nine mothers (44%) reported offering items other than breastmilk. The median contribution of energy from complementary foods among infants with mixed feeding (n=66) was 197 kcal/day (interquartile range [IQR] 49-353). The median energy contribution of formula or cow's milk among consumers (n=39) was 212 kcal/day (IQR 84-394). Bottles were used on the previous day by 55 (80%) of the 69 mothers not offering exclusive breastfeeding. Conclusions. Premature introduction of non-breastmilk items is commonly practiced in feeding Guatemalan infants. Adherence to the internationally recognized guidelines for early infant feeding should be an intervention priority for this population.

Objetivos. Examinar la naturaleza y contribución energética de la alimentación complementaria en infantes lactantes en el sexto mes de vida y la prevalencia del uso de biberones como método de alimentación. Material y métodos. Se seleccionaron 156 infantes lactantes en un centro de salud en la ciudad de Quetzaltenango, Guatemala. Se solicitó una rememoración de la alimentación del día anterior. Resultados. Sesenta y nueve madres (44%) reportaron dar alimentos adicionales a la leche materna. La mediana de contribución energética de alimentos complementarios en infantes con alimentación mixta (n=66) fue 197 kcal/día (rango intercuartil [RIC] 43-353). La mediana de contribución energética de leche de vaca entre consumidores (n=39) fue 212 kcal/día (RIC 84-394). De 69 madres que ofrecían alimentación mixta, 55 (80%) proporcionaron biberones. Conclusiones. Las madres guatemaltecas practican comúnmente la introducción prematura de la alimentación complementaria. La adhesión a las guías internacionalmente reconocidas para alimentación de infantes debe ser una prioridad de intervención en esta población.

HIV stigma and disclosure experiences of people living with HIV in an urban and a rural setting.

Human immunodeficiency virus (HIV) remains a highly stigmatised condition for people living with HIV (PLWH) and people living close to them (PLC) globally. The research objectives for this study were to explore and describe how HIV stigma and disclosure experiences impact the lives of PLWH and to explore whether there are differences between experiences in urban and rural settings. A qualitative approach was followed and participants were selected through purposive voluntary sampling. Data collection took place using in-depth interviews with 23 PLWH, 11 of whom resided in an urban setting in North-West, South Africa, and 12 resided in a rural setting in the same province. The data were manually analysed through open coding. The HIV stigma experiences expressed by PLWH depicted negative behavioural patterns and attitudes towards them, fear from the community of being infected by PLWH and lastly negative self-judgement by PLWH themselves. During disclosure, PLWH were unsure and they described it as a stressful event. They cautiously considered to whom to disclose their condition and what benefits disclosure will hold. They further had to handle forced disclosure due to being identifiable in health-care settings. HIV stigma and related disclosure practices remained a problem, which detrimentally affected treatment and support efforts. Recommendations focused on HIV stigma reduction in the community that needed to involve PLWH and PLC.

Helminth infections and micronutrients in school-age children: a systematic review and meta-analysis.

BACKGROUND: Helminth infections and micronutrient deficiencies are highly prevalent in developing countries. Neither condition typically causes overt disease, but they do lead to indirect morbidity such as impaired physical and cognitive development. OBJECTIVE: We aimed to systematically review current evidence on the relation of helminth infections with micronutrient status in school-age children worldwide. DESIGN: We included both observational studies and randomized controlled trials (RCTs). We applied a random-effects meta-analysis to estimate 1) cross-sectional associations between helminths and micronutrient status, 2) effects of anthelminthic treatment on micronutrient status, and 3) effects of micronutrient supplementation on helminth infection and reinfection. RESULTS: Meta-analyses of observational studies showed an association between helminth infections and serum retinol [standardized mean difference (SMD): -0.30; 95% CI: -0.48, -0.13] but not serum ferritin (SMD: 0.00; 95% CI: -0.7, 0.7). Conversely, meta-analyses of anthelminthic treatment RCTs showed a positive effect on ferritin (SMD: 0.16; 95% CI: 0.09, 0.22) but not retinol (SMD: 0.04; 95% CI: -0.06, 0.14). The number of studies on micronutrients other than ferritin and retinol was not sufficient for pooling. Meta-analyses of micronutrient-supplementation RCTs showed only a modest protective effect for multimicronutrient interventions on helminth infection and reinfection rates (OR: 0.77; 95% CI: 0.61, 0.97). CONCLUSIONS: In this review, we show evidence of distinct associations between helminth infections and micronutrients in school-age children. More studies are needed on micronutrients other than iron and vitamin A and on possible helminth species-specific effects. A thorough comprehension of the interplay between helminth infections and micronutrients will help guide integrated and sustainable intervention strategies in affected children worldwide.

Challenges in the elaboration of a field interview instrument to capture information for the evaluation of adherence to the WHO/PAHO Guiding Principles for Complementary Feeding of the Breastfed Child.

BACKGROUND: In 2003, the World Health Organization (WHO) and the Pan American Health Organization (PAHO) published "Guiding principles for complementary feeding of the breastfed child," which includes a series of 10 recommendations. OBJECTIVE: To illustrate the challenges in creating operative criteria for the evaluation of concordance with the tenets of the WHO/PAHO Guiding Principles recommendations. METHODS: We set out to define operative criteria for the evaluation of adherence to the tenets of the WHO/PAHO Guiding Principles. The 10 Guiding Principles were divided into subcomponents and examined carefully. Our indicators were based on evaluation variables collected by means of our prospectively designed data collection tool. The 2008 WHO-validated infant and young child feeding (IYCF) indicators were taken as a reference for evaluation. RESULTS: After careful examination of the 10 WHO/PAHO Guiding Principles, we were able to identify 28 specific subcomponents for evaluation. With our prospectively designed data collection tool, we were able to set evaluations for 17 of these 28 subcomponents. CONCLUSIONS: The considerations for devising the criteria involved in evaluation instruments must be transparently available to clarify the interpretations and conclusions derived from their application. Evaluation criteria can be set for most, but not all, IYCF practices of the WHO/PAHO Guiding Principles. Indicators that focus on selected, food-related dimensions of childfeeding can be measured in large surveys, whereas other dimensions of optimal feeding, such as hygienic food handling and adequate texture of food, are likely to require more complex measurement and evaluation approaches.

Obesity and cardiovascular disease risk factors among the indigenous and immigrant Pakistani population: a systematic review.

AIM: The aim of this study was to systematically describe the gender and ethnic differences regarding the prevalence of general/central obesity and cardiovascular disease (CVD) risk factors such as diabetes mellitus type 2, hypertension, and hypercholesterolemia among the indigenous and immigrant Pakistani communities. METHODS: The search engine used was PubMed, supplemented with regional data from the Medical Institutes of Pakistan. The focus was on the adult Pakistani population (18 years and older). RESULTS: We found only 7 studies among the immigrant Pakistani community and 24 studies among the indigenous Pakistani community. The studies had limitations such as low participation rates and use of self-reported data. There is a higher prevalence of central obesity among women (42.2%) than among men (14.7%) (National Health Survey of Pakistan). Certain ethnicities such as Muhajir and Baluchis showed a higher prevalence of cardiovascular risk factors when compared to other ethnicities in the indigenous Pakistani population. The results also indicate that the prevalence of obesity is 10-20% higher among the immigrant Pakistanis than in the indigenous Pakistanis. CONCLUSION: The relatively high prevalence of obesity and associated CVD risk factors (especially in women) among both indigenous and immigrant Pakistani populations require the attention of the healthcare professionals and policy makers, both inside and outside Pakistan.

Estimates of exclusive breastfeeding rates among mother-infant dyads in Quetzaltenango, Guatemala, vary according to interview method and time frame.

BACKGROUND: The World Health Organization (WHO) recommends exclusive breastfeeding, defined as receiving only breastmilk, through the first 6 months of life to optimize survival, health, and development. OBJECTIVE: To assess exclusive and predominant breastfeeding rates, as defined by WHO, in a sample of Guatemalan infants using three dietary assessment methods. METHODS: Mothers of 156 infants (78 boys and 78 girls) in the 6th month of life, attending a public health center in Quetzaltenango, an urban area located in the Highlands of Guatemala, were recruited. A single face-to-face interview was performed to assess infant dietary intake using three methods: previous day dietary recall (as suggested by WHO), current feeding practices, and recall of feeding practices since birth. RESULTS: Based on the previous day dietary recall method, exclusive breastfeeding was reported by 87 (56%) of the mothers. Exclusive breastfeeding rates were much lower when estimated by current feeding practices questions (20%) and even lower when based on recall of feeding practices since birth (9%). The sum of exclusive and predominant breastfeeding (full breastfeeding) rates was 58%, 49%, and 31% based on previous day dietary recall, current feeding practices, and recall of feeding practices since birth, respectively. CONCLUSIONS: The WHO method of dietary assessment, based solely on the previous day dietary recall, overestimates the exclusive breastfeeding rate compared with recall of feeding practices since birth. In our population sample, adherence to the WHO guidelines for feeding in the first semester of infancy was less than ideal and in need of strengthening.

Stunting rates in infants and toddlers born in metropolitan Quetzaltenango, Guatemala.

OBJECTIVE: Guatemala has the highest prevalence of stunting (54% of children under age 5 years) in the Americas and the fifth highest in the world. The aim of this study was to describe the stunting prevalence and the association with early feeding practices, morbidity patterns, and socioeconomic status (SES) in a sample of infants and toddlers from urban Quetzaltenango. METHODS: We recruited 299 children (149 boys), ages 6-23 mo from two public health clinics in metropolitan Quetzaltenango. Data on SES, early feeding practices, and morbidity were collected by means of a single face-to-face interview. Recumbent spine length was measured according to standardized procedures and height-for-age (HAZ) z-scores were calculated. HAZ <-2 SD of the World Health Organization's 2006 Growth Standards was considered stunting. Multiple logistic regression analysis was used to examine determinants of stunting. RESULTS: The overall mean HAZ z-score was -1.89 ± 1.11 and 135 (45%) children were stunted. The results of the crude odds ratios showed that place of interview (suburban), being male, being ages 13-18 mo, being born at home, having a mother with a low level of education, being of Mayan (indigenous) ethnicity, having a mother with short stature, and having ever received iron supplementation were strongly and significantly (P < 0.05) associated with stunting. None of the other variables, such as supplement use and morbidity rates, contributed to the predictive model. We did not observe an association between early feeding practices or morbidity and stunting. CONCLUSION: The stunting prevalence exceeds the cut-off of 40% stunting, indicating a community with a high level of malnutrition.

Breastfeeding and food pattern in overweight children in the Caribbean.

BACKGROUND: As in most countries around the globe, overweight and obesity are a major threat to public health on the Caribbean island of Aruba. Increasing evidence confirms that breastfeeding protects against overweight and obesity. However, little is known about the mechanism underlying the association between breastfeeding and obesity. One possibility is that breastfed infants are better able to control their meal size and intervals than formula-fed infants. This might lead to a healthier diet in later life and protect against overweight and obesity. OBJECTIVE: To determine the relationship between breastfeeding, food pattern and being overweight in the Caribbean. METHODS: In a cross-sectional school-based study in 2004-2005, weight and height were measured by two research assistants in 1776 children aged 6-11 years on Aruba, an island in the Caribbean. BMI was defined according to guidelines by the International Obesity Task Force. Parents completed a questionnaire pertaining to breastfeeding and dietary food pattern. RESULTS: 1451/1776 (81·7%) children were breastfed; 851/1766 (47·9%) children were breastfed for <4 months, 227/1776 (12·8%) for 4-6 months and 373/1776 (21·0%) for ≥6 months. Children who were breastfed for ≥4 months had lower odds (OR 0·32, 95%CI 0·25-0·40) of being overweight including obesity than those who either were not breastfed or who were breastfed for <4 months. Children who were breastfed for ≥4 months were more likely to have a structured food pattern of six eating moments a day (OR 7·43, 95% CI 5·87-9·39, P<0·001) and to have breakfast every day (OR 2·86, 95% CI 2·17-3·78, P<0·001) than those who were not or who were breastfed for <4 months. CONCLUSIONS: Breastfeeding for ≥4 months is associated with a structured food pattern (six eating moments a day including a daily breakfast) and carries a strikingly lower risk of overweight in children. Promoting prolonged breastfeeding together with a focus on a subsequent structured food pattern could be a cheap method of preventing overweight.