Prolonged Bottle Use and Obesity at 5.5 Years of Age in US Children

Article Outline

• Abstract
• Methods
  • Statistical Analysis
• Results
• Discussion
• References
• Copyright

Objective

To examine the association between prolonged bottle use and the risk of obesity at 5.5 years of age.

Study design

Data from the Early Childhood Longitudinal Study, Birth Cohort were analyzed for 6750 US children born in 2001. The outcome was obesity (body mass index ≥95th percentile) at 5.5 years, and the exposure was parental report of the child using a bottle at 24 months.

Results

The prevalence of obesity at 5.5 years was 17.6%, and 22.3% of children were using a bottle at 24 months. The prevalence of obesity at 5.5 years was 22.9% (95% CI, 19.4% to 26.4%) in children who at 24 months were using a bottle and was 16.1% (95% CI, 14.9% to 17.3%) in children who were not. Prolonged bottle use was associated with an increased risk of obesity at 5.5 years (OR, 1.33; 95% CI, 1.05 to 1.68) after controlling for potential confounding variables (sociodemographic characteristics, maternal obesity, maternal smoking, breastfeeding, age of introduction of solid foods, screen-viewing time, and the child’s weight status at birth and at 9 months of age).

Conclusions

Prolonged bottle use was associated with obesity at 5.5 years of age. Avoiding this behavior may help prevent early childhood obesity.

BMI, Body mass index, ECLS-B, Early Childhood Longitudinal Study, Birth Cohort, WIC, Special Supplemental Nutrition Program for Women, Infants and Children

There is agreement among experts in pediatrics, nutrition, and public health that childhood obesity prevention should begin before children enter school,¹, ² but evidence is lacking about which interventions are effective.³ Awaiting such evidence, pediatricians and other professionals who advise the parents of toddlers and preschool-aged children about obesity prevention are trying to identify which health behaviors to target. Candidate behaviors might be those that, if implemented, would be unlikely to do harm, may prevent obesity, and may also have health benefits unrelated to obesity prevention.⁴

Drinking from a bottle beyond infancy is a behavior that could contribute to obesity by encouraging the child to consume excess calories. Prolonged bottle use is defined as using a bottle later than 12 to 14 months of age⁵ and can include using a bottle to feed the child liquids during meals and snacks, putting a child to bed with a bottle, or both.⁶ Prolonged bottle use is thought to be one potential cause of both iron deficiency⁷ and early childhood caries.⁸, ⁹ The American Academy of Pediatrics recommends that parents avoid putting their children to bed with a bottle containing anything other than water as a strategy for preventing early childhood caries,¹⁰ but this recommendation is not mentioned as an obesity prevention strategy.¹

Few studies have explored the association between prolonged bottle use and the risk of obesity in children, and all have been cross-sectional.¹¹, ¹², ¹³, ¹⁴ One study found a positive association between bedtime bottle use and obesity in 3-year-old children living in 20 large US cities.¹⁴ We are aware of no longitudinal studies that have examined the relationship between prolonged bottle use and obesity. With recent data from a cohort study of US children born in 2001, we examined the association between bottle use at 24 months of age and obesity at 5.5 years of age.

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Methods 

We analyzed data collected in the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B). The study was conducted by the National Center for Education Statistics, the ethics review board of which approved the study. Parents provided written informed consent. Analyses reported here were conducted at The Ohio State University under a restricted-use data agreement. This agreement requires that we report unweighted sample sizes by rounding to the nearest 50.

The sampling design of ECLS-B has been previously described and is summarized briefly here.¹⁵ A clustered list-frame design was used to select a probability sample of 14 000 US births in 2001. To obtain reliable prevalence estimates for certain demographic groups, these groups were purposefully over-sampled: Chinese American children, American Indian/Native Alaskan children, children born at low birth weight, and twins. Children were excluded from the study when they were born to mothers <15 years of age or when, before 9 months of age, they had died or were adopted. When the children were approximately 9 months of age, the final study cohort of 10 700 was formed. Of these children, 9850 were assessed again at approximately 24 months of age, and 8750 were assessed at approximately 4.5 years of age. For budgetary reasons, 85% of those participating at 4.5 years of age were randomly selected for follow-up at 5.5 years of age, and 6950 children were assessed at that time. Data were collected during visits to the children’s homes. The mother (or, in a small number of cases, the father or other guardian) was interviewed.

Our primary exposure variable was the behavior of prolonged bottle use. This variable was derived from two questions at the 24-month interview. Parents were asked whether the child “primarily” drank from a bottle, sippy cup, or a regular cup. When the primary drink container was a bottle, the child was considered to be a regular bottle user. In addition, parents were asked whether they “usually” put the child to bed with a bottle. When the response was yes, the child was considered a bedtime bottle user. We categorized children as having prolonged bottle use when they were regular or bedtime bottle users at 24 months of age. All other children were categorized as not using a bottle at 24 months.

We defined children’s obesity status at age 5.5 years relative to the 2000 US growth reference.¹⁶ With a standardized protocol, children’s heights were measured with a portable stadiometer and children’s weights were measured with a digital scale while they were wearing light clothing and no shoes.¹⁷ We calculated body mass index (BMI, kg/m²) and categorized children as obese when they had a sex-specific BMI-for-age ≥95th percentile.¹⁸

Potentially confounding variables were grouped in 4 domains: (1) sociodemographic characteristics; (2) maternal health; (3) modifiable behaviors associated with obesity; and (4) child’s earlier weight status. We chose these variables on the basis of their established relationship with obesity and their likely relationship with prolonged bottle use.

Child sex, twin status, racial/ethnic group, maternal education, income-to-poverty ratio, and residence in a single-parent household were all derived from responses to the 9-month parent questionnaire. The household income-to-poverty ratio was calculated relative to 2002 US poverty levels.¹⁹

Mothers were classified as smokers when they reported smoking cigarettes at the time of the 9-month interview. Mothers reported their height and were weighed on a digital scale with the same protocol used for the children at 5.5 years. When maternal weight was missing at 9 months but available at 24 months, 4.5 years, or 5.5 years, we used the earliest available weight value to calculate maternal BMI. No data were available on paternal height and weight.

At the 9-month interview, mothers were asked whether they had ever breastfed the child and the age of the child at weaning. Data were not available to determine the practice or duration of exclusive breastfeeding. Mothers were also asked at what age they introduced their child to solid foods. Children’s screen-viewing time was assessed at 24 months. Parents reported the average amount of time children spent watching television or videos, and they provided separate responses for weekdays and weekend days. By using these estimates, we calculated the average screen-viewing time per day as a weighted average of weekday and weekend viewing. We defined two categories of screen-viewing time (≤2 hours per day and >2 hours per day) based on American Academy of Pediatrics recommendations.²⁰

Children’s birth weight was obtained from birth certificate records. At the 9-month assessment, children’s length was measured with a measure mat, and their weight was obtained with a digital scale by subtracting the weight of the parent measured alone from the weight of the parent while holding the child.²¹ We calculated children’s weight-for-length percentile with the 2000 US growth reference.¹⁶

Statistical Analysis 

Our analyses included all children who had available data on bottle use at the 24-month interview and measured height and weight at the 5.5-year assessment (n = 6750). We applied ECLS-B sample weights, which include adjustments for non-response and planned oversampling.²² Standard errors and 95% CI that account for the complex sample design were calculated by using replicate weights,²³ as implemented in the survey procedures in SAS (SAS Institute Inc, Cary, North Carolina).²⁴ This technique accounts for clustering due to ECLS-B’s complex sample design and the correlated observations for twins.

We first determined the association of co-variates with the prevalence of prolonged bottle use and with obesity at 5.5 years of age. We then used logistic regression models to estimate the odds of obesity at age 5.5 years associated with prolonged bottle use. We present ORs and 95% CI that are unadjusted and ORs that are adjusted for co-variates. The child’s age in months at the 24-month assessment and maternal BMI were modeled as continuous variables.

We conducted analyses to address the possibility of reverse causality—that prolonged bottle use might occur in response to infants who are prone to be obese. We considered children prone to obesity in infancy on the basis of having high weight-for-length at 9 months or an obese mother. We separately examined the association between prolonged bottle use and obesity at 5.5 years in children with and without high weight-for-length at 9 months (≥95th percentile versus <95th percentile) and in children with and without obese mothers (maternal BMI ≥30 kg/m² versus <30 kg/m²). By using cross-product interaction in logistic regression, we also tested the statistical significance of the interaction between prolonged bottle use and weight-for-length at 9 months and between prolonged bottle use and maternal obesity.

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Results 

Of the 6750 children in our analyses, 17.6% were obese at 5.5 years of age and 22.3% of children were bottle users at 24 months of age (18.9% were bedtime bottle users and 10.5% were regular bottle users). There were clinically meaningful differences in the prevalence of obesity across levels of all 13 co-variates examined. This was also true for the prevalence of prolonged bottle use across levels of several of these co-variates (Table I).

Table I. Prevalence of prolonged bottle use and obesity at 5.5 years according to sample characteristics

	Sample characteristics	Prolonged bottle use		Obesity§at 5.5 years
	n (%)∗	% (95% CI)†	P value‡	% (95% CI)†	P value‡
Sociodemographics
Sex			.52		.03
Girls	3350 (49.1)	22.8 (20.4-25.2)		16.2 (14.4-18.0)
Boys	3400 (50.9)	21.7 (19.5-24.0)		19.0 (17.1-20.8)
Twin			.20		.002
Yes	1150 (2.9)	24.1 (21.0-27.3)		12.5 (9.8-15.1)
No	5600 (97.1)	22.2 (20.5-23.9)		17.8 (16.4-19.1)
Racial/ethnic group			<.001		<.001
White, non-Hispanic	2750 (53.7)	15.4 (13.5-17.4)		13.7 (12.1-15.2)
Black, non-Hispanic	1150 (15.5)	15.1 (12.5-17.6)		20.4 (17.1-23.6)
Hispanic	1250 (24.2)	38.1 (33.4-42.8)		24.0 (20.5-27.5)
Other	1550 (6.6)	36.7 (32.1-41.3)		19.6 (15.2-24.1)
Maternal education			<.001		<.001
College graduate	1950 (24.5)	15.8 (13.6-18.0)		12.1 (10.2-13.9)
Some college	1900 (28.1)	18.9 (16.3-21.4)		17.0 (14.5-19.5)
High school degree	1800 (28.3)	24.5 (21.3-27.8)		21.0 (18.1-23.9)
Less than high school degree	1200 (19.0)	32.4 (28.3-36.6)		20.7 (17.6-23.8)
Income-to-poverty ratio			<.001		<.001
>3.00	1700 (24.7)	17.6 (15.0-20.2)		13.8 (11.5-16.0)
1.86-3.00	1800 (27.3)	19.7 (17.0-22.4)		14.5 (11.9-17.1)
1.00-1.85	1650 (24.6)	25.3 (21.8-28.9)		20.8 (17.9-23.7)
0.50-0.99	850 (13.1)	27.4 (22.7-32.0)		23.0 (18.8-27.1)
<0.50	800 (10.4)	26.3 (23.0-29.7)		20.4 (17.0-23.9)
Single parent			.81		.002
No	5400 (79.7)	22.2 (20.4-24.0)		16.7 (15.2-18.1)
Yes¶	1350 (20.3)	22.6 (19.5-25.6)		21.2 (18.5-23.9)
Maternal Health
Smoking status			.71		.009
Non-smoker	5500 (81.3)	22.2 (20.3-24.0)		16.7 (15.2-18.2)
Smoker	1250 (18.7)	22.8 (19.5-26.1)		21.7 (18.2-25.2)
BMI			.43		<.001
<30 kg/m2	4700 (72.1)	21.9 (20.0-23.7)		12.9 (11.5-14.2)
≥30 kg/m2	1800 (27.9)	23.1 (20.1-26.0)		29.2 (26.5-32.0)
Modifiable behaviors
Breastfeeding			.04		<.001
≥6 months	850 (13.9)	19.6 (16.1-23.1)		13.3 (10.4-16.3)
2-5 months	1600 (22.3)	24.9 (21.9-28.0)		17.5 (14.8-20.2)
<2 months	2150 (33.4)	20.8 (18.6-23.0)		15.9 (13.8-18.0)
Never	2050 (30.4)	23.4 (20.4-26.4)		21.3 (18.4-24.3)
Introduction of solid foods			.43		<.001
≥6 months	2250 (27.4)	22.9 (19.9-25.9)		16.5 (14.5-18.6)
4-5 months	3200 (49.3)	21.4 (19.5-23.2)		16.2 (14.4-18.0)
≤3 months	1350 (23.2)	23.4 (20.0-26.8)		21.8 (18.9-24.7)
Screen-viewing time at 24 months			<.001		<.001
≤2 hours per day	4000 (60.2)	18.8 (17.0-20.7)		15.5 (14.1-16.9)
>2 hours per day	2650 (39.8)	27.4 (24.8-30.1)		20.8 (18.3-23.2)
Prior child weight status
Birth weight			.055		<.001
<1500 g	650 (1.2)	33.8 (29.8-37.9)		9.2 (6.6-11.8)
1500-2500 g	1000 (6.2)	23.4 (19.8-26.9)		12.4 (9.8-14.9)
2501-4000 g	4600 (83.1)	22.2 (20.3-24.1)		17.0 (15.6-18.4)
>4000 g	450 (9.5)	20.4 (15.6-25.1)		27.4 (22.3-32.6)
Weight-for-length at 9 months			.23		<.0001
<5th percentile	400 (5.8)	20.5 (13.9-27.1)		7.2 (3.6-10.8)
5th-49th percentile	2050 (30.8)	22.9 (19.5-26.2)		8.6 (6.9-10.3)
50th-84th percentile	2050 (32.7)	20.8 (18.3-23.3)		16.0 (13.6-18.4)
85th-94th percentile	900 (15.0)	23.2 (18.3-28.0)		21.7 (17.7-25.6)
≥95th percentile	850 (15.8)	26.7 (22.3-31.1)		38.1 (34.1-42.1)

The prevalence of obesity at 5.5 years was similar in children who were only bedtime bottle users and children who were only regular bottle users (Table II), and most regular bottle users (67.8%) were bedtime bottle users. Therefore, in subsequent analyses, we examined the association between obesity at 5.5 years and prolonged bottle use (either regular or bedtime bottle use).

Table II. Prevalence and odds of obesity at 5.5 years by bottle use at 24 months

The prevalence of obesity at 5.5 years of age was 22.9% (95% CI, 19.4% to 26.4%) in prolonged bottle users and was 16.1% (95% CI, 14.9% to 17.3%) in children not using a bottle. The unadjusted odds of obesity for children with prolonged bottle use were 1.55 times (95% CI, 1.27 to 1.90) the odds for children not using a bottle (Table III). In a series of regression models, domains of co-variates were entered in a step-wise fashion, and prolonged bottle use remained a risk factor for obesity after adjusting for these potentially confounding variables (Table III). After adjusting for all co-variates, the odds of obesity were 1.33 times (95% CI, 1.05 to 1.68) higher for children who were using a bottle at 24 months than for children who were not.

Table III. Odds of obesity at 5.5 years associated with prolonged bottle use

In stratified analyses, the association between prolonged bottle use and obesity was present in children prone to obesity in infancy and children who were not. The association did not differ meaningfully by the child’s weight status at 9 months or between children of obese mothers and children of non-obese mothers (data not shown). The cross-product interaction terms in logistic regression models were not statically significant (child weight status at 9 months by prolonged bottle use, P = .38, and maternal obesity by prolonged bottle use, P = .43).

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Discussion 

In this longitudinal study, the use of a bottle at 24 months of age was positively associated with having a BMI ≥95th percentile at 5.5 years of age. Prolonged bottle use was associated with obesity after accounting for many potentially confounding factors, such as indicators of socioeconomic status, maternal BMI, early infant feeding practices, and weight at birth and at 9 months of age. This is the first prospective study in a large national sample to analyze the relationship between the potentially modifiable behavior of prolonged bottle use and the prevalence of obesity in early childhood.

Prolonged bottle use may lead to the child consuming excess calories, particularly when parents are using the bottle to comfort the child rather than to address the child’s hunger or nutritional needs. For example, a 24-month-old girl of average weight (approximately 12 kg) and length (approximately 86 cm) who is put to bed with an 8-ounce bottle of whole milk (approximately 150 kcal) would receive approximately 12% of her daily caloric needs (approximately 1300 Kcal) from that bottle.²⁵, ²⁶ To the extent that some calories obtained from the bottle are in excess of the child’s needs, this could contribute to weight gain over time.²⁷, ²⁸

The association between prolonged bottle use and obesity has been suggested in earlier cross-sectional studies. In a small study examining children enrolled in clinics of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in New York City (n = 95, mean age = 36 months) current bottle use was associated with BMI ≥95th percentile.¹¹ In another small sample taken from New York City WIC clinics (n = 103, age range = 12 to 36 months), current bottle use was associated with weight-for-length ≥95th percentile.¹³ With data collected in the National Health and Nutrition Examination Survey III (1988 to 1994), Bonuck et al showed that weaning from the bottle at an older age was associated with higher BMI in 3- to 5-year-old children.¹² In the only study that has examined the specific behavior of bedtime-bottle use and weight in preschool-aged children, Kimbro et al found a higher risk of BMI ≥85th percentile in 3-year old children who still used a bedtime bottle at that age (adjusted OR, 2.10; P < .001).¹⁴ In a randomized trial to prevent iron depletion at 2 years of age, parents in the intervention group were counseled during their child’s routine health maintenance visit at 9 months of age to discontinue bottle use at that time.²⁹ At 2 years of age, children in the intervention group were less likely to use a daytime bottle (40% versus 15%, P = .0004) or a bedtime bottle (10% versus 3%, P = .05). There was no significant effect of the intervention on either iron depletion or BMI. These findings are a reminder that experimental and observational studies can have conflicting results and that one must be cautious in making causal inferences from observational studies.

Despite the use of data from a recent national cohort study, our observational study had several limitations. We lacked data on some potentially confounding variables, such as children’s physical activity and specific aspects of their diet. For example, it is possible that children who were using a bottle at 24 months of age were more likely to be overfed in general, were more likely to consume sugar-sweetened beverages, or were less likely to be exclusively breastfed. Unmeasured differences between children studied at 5.5 years and children lost to follow-up could have influenced the association we observed, and we cannot determine the magnitude or direction of this influence. However, we found no significant differences in prolonged bottle use, 9-month weight status, or maternal BMI between children who were followed at 5.5 years of age and children who were not. There could have been some misclassification of our exposure because prolonged bottle use may have been inaccurately reported by parents; however, if there was more underreporting of this behavior at 24 months of age by parents of heavier children, this would have decreased the magnitude of the association we found. Finally, because obesity was a relatively common outcome, ORs will overestimate risk ratios.³⁰

A multilevel obesity prevention strategy is considered optimal because it alters children’s social and physical environments in multiple settings, such as the home, child care, school, and neighborhood.², ³¹, ³² However, the health care system is another important setting to consider because this is where families often turn for information about health and nutrition for their children. Pediatricians and other health professionals seek to provide advice about specific, modifiable behaviors that may prevent obesity. Prolonged bottle use may be one such behavior. Advising parents to avoid using the bottle after the child’s first birthday is unlikely to cause harm and may prevent obesity along with other health problems.

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