Breastfeeding and Diabetes
by DP Meulenberg
Breastfeeding has a close relationship with diabetes, because of (a) the opinion often expressed that breastfeeding is protective against diabetes in the child, (b) the growing number of nursing mothers who have diabetes and are concerned about how this affects their ability to provide beneficial milk, and (c) the increasing amount of health data that shows direct, close correlations between highs and lows in breastfeeding rates and corresponding highs and lows in childhood diabetes incidence. This article will focus mainly on the evidence referred to in (c) above. Evidence will also be presented about the biological connection between breastfeeding and diabetes.
We will start out looking at the recent history of the many varying changes in levels of breastfeeding (different among various countries and demographic groups and at different times); we will then compare those changes with national historical health data regarding the many different changes in levels of childhood diabetes for the periods that directly followed the variations in breastfeeding. Based on considerable data covering the period since 1970, breastfeeding and child diabetes have correlated very closely in their highs, lows, and mid-levels over time, among nations, and among demographic groups.
Section 1.a: Some relevant historical data for the U.S.
According to the American Academy of Family Physicians, breastfeeding rates in the U.S. were low during the middle of the 20th century.(1) Figure 1 shows how those rates rapidly increased beginning in the early 1970's, following a slow increase beginning in 1966.
According to the president of the American Diabetes Association, type 2 diabetes as of 2002 had "changed from a disease of our grandparents and parents to a disease of our children." At that time it was on its way to being what she called a "new epidemic" among children and young adults.(6) Considering when the children must have been born who made up the "new epidemic" among children and young adults as of 2002, major increases in diabetes very likely occurred among those born somewhere around 1970 and later. Observe in Figure 1 above how that relates to the time of the major increases in breastfeeding. Details will follow.
Unfortunately, there is little data available regarding diabetes prevalence among young people for the period of the 1960's to the early 1980's. The only readily-found study on the history of the increase of childhood diabetes states, "the rising incidence of the condition was not widely recognized until the 1980s." (7d) If rising incidence of a slowly-developing disease became widely recognized in the 1980's, actual beginnings of the increase sometime in the 1970's would be very compatible with such a time range.
During its first two decades, this "new epidemic" was apparently only among children, the group directly affected by the recent increases in breastfeeding; the first reference found by this author (after substantial search) to inclusion of young adults within this epidemic was in 2002. That is fully compatible with the birth years of the new diabetics being after the mid-1960's. Again, see how that relates to the period of increasing breastfeeding as shown in Figure 1 above.
Section 1.b: Ethnic/historical data in the U.S.
The president of the American Diabetes Association also pointed out in 2002 that diabetes had risen especially rapidly among African-American children; (6) in that regard, it should be noted that breastfeeding rates rose many times more rapidly among black women than among other ethnic groups in the decade just before 2002.(7) It may be more than coincidental that both of these (possibly unique) increases were in the same ethnic group and during the same time period.
In this graph on the left,(7f) notice that the prevalence of type 1 diabetes (the predominant type among children) for U.S. 0-9-year-olds is highest among non-Hispanic whites (NHW) and just over half as high among African Americans. This correlates with the well-established fact that breastfeeding rates are highest among whites and about half as high among blacks. a1a (see Section 1.2.s.3 of http://www.pollutionaction.org/breastfeeding-and-autism-and-cancer.htm)
Section 2: International comparisons regarding childhood diabetes
Section 2.a: In Western Europe, type 1 diabetes among children aged 0-14 is 2.6 times as prevalent in the highest-breastfeeding as in low-breastfeeding countries, on average. (see Figure 3 on right) Norway, Sweden and Finland can be easily seen at the tops of both the diabetes and the breastfeeding charts on the right. It requires a closer look to see France, Ireland and U.K. at the lower levels in both charts. Poland does not appear on this breastfeeding chart, but there is other evidence to place it in the lower-breastfeeding category, despite its recent increases in that area. (See Figure 6 and (8)) Note that Poland’s relatively low breastfeeding rate matches its fairly low diabetes incidence.
Notice that only Austria, as a late arrival, shares the highest levels of the breastfeeding rates chart with the three Scandinavian countries; and its trend of childhood type 1 diabetes is of interest. The only readily-found study of Austria's recent childhood diabetes trends indicates an increase of about 180% in childhood diabetes between 1989-1991 and 2001-2005,(8c) coinciding with its huge increase in breastfeeding indicated by the steep upward angle of Austria's line (1985-1997) in this chart of breastfeeding rates.
Sweden's case is also revealing. A 1999 study showed that Sweden's childhood diabetes incidence was increasing, (8d) whereas a 2012 study reported that Sweden's childhood diabetes rate had apparently reached "a plateau." (8e) Both the increase and the subsequent extended leveling are entirely compatible with the earlier increase and the subsequent leveling/slight decline of Sweden's breastfeeding rate as shown in this chart.
It was found by Finland's national health system that their overall type 1 diabetes rates more than doubled between 1980 and 2005,(8e2) which is entirely compatible with its increases in breastfeeding shown for that same period in Figure 3 above. The changes over time of breastfeeding rates in Finland during that overall period is also worth a close look, as follows:
a) the rate of increase in diabetes of the 0-4 age group during much of the 1990's was less than half of what it had been before and what it was after that period; (8e2a)
b) in that regard, note in the above chart the slowdown in breastfeeding in Finland during the early 1990's.
Fig. 4 Breastfeeding rates in Norway
One article in the journal Diabetologia tells of a relevant trend, which is stated in its title: "Increasing incidence of diabetes mellitus in Norwegian children 0-14 years of age 1973-1982." (8a) (italics added) A later article by the same authors reported an end to that increase, again reflected in its title: "No increase in incidence of type I diabetes in young children in Norway 1989-1998." (8b) Knowing of the country's sharp increase in breastfeeding rates during the 1970's (see Figure 4) and seeing its flat breastfeeding rate in later years as shown in the lower chart of Figure 3 above, one doesn't have to think very hard to see a correlation between Norway's changing breastfeeding rate and a similar change in that country's incidence of childhood diabetes.
"Especially striking" increases in diabetes in a very specific region, time period and age group:
In a study of over 29,000 cases of childhood type 1 diabetes across Europe over the period 1989-2003, the authors pointed out that "the rapid rise of type 1 diabetes in the youngest age-group in regions in central and eastern Europe are especially striking." (8f2) Another study, indicating increases in type 1 diabetes in Europe during 1989-98, showed that the incidence trend among the 0-4 age group in central and eastern Europe was a full 76% higher than the figure for the group with the second-highest increase, when comparing with all age groups in all six of the other European regions. (8f3)
Extraordinary increases in breastfeeding in that very same region, time period and age group
Take note of the abbreviation, CEE/CIS, which stands for Central and Eastern Europe and Commonwealth of Independent States (all former Soviet Bloc states); then observe in this chart which specific world region has gone through a very exceptional increase in breastfeeding rates in the last two decades, which paralleled its exceptional increase in childhood diabetes. Bear in mind from the previous paragraph that the increases in diabetes had been especially high in the 0-4 age group, the group that would obviously have been most directly affected by the simultaneous huge increases in breastfeeding.
(During the Soviet era -- before 1990 -- exclusive breastfeeding was apparently actively discouraged in this entire CEE/CIS region. Various sources verify this fact as well as the reversal of that policy in the post-Soviet era, with extensive U.S. and international support for the transition in breastfeeding.) (8fa)
Childhood diabetes rates in this formerly-low-breastfeeding CEE region, as of before the major increases of the 1990's and early 2000's, were about one-third to one-fifth as high as those in high-breastfeeding Norway, Sweden and Finland. (8f) That is compatible with the differences in breastfeeding rates between those two groups of countries as of that time.
Aside from general statistics for the region, some specifics are at least as revealing, especially when considering changes over time. A look at the WHO chart below will quickly reveal a conspicuous low-to-high rising star in breastfeeding in the Eastern/Central European region, Hungary. One has to look only a little closer to see another country (Armenia) that also had an extremely rapid, several-fold increase during that period. What happened with those two countries' childhood diabetes rates following those breastfeeding increases is discussed below the chart.
Fig. 6: Central and Eastern European Countries
According to the Chief Endocrinologist of the Republic of Armenia Ministry of Health in 2011, "in Soviet Armenia the number of diabetics used to increase by 1000 a year, while in the Republic of Armenia the number increases by 4000-5000." (8z6) He is referring to a low diabetes incidence during the Soviet era when breastfeeding rates were also low, as compared with the extraordinarily increased diabetes incidence during the period after breastfeeding rates had increased several-fold. (see chart above)
A study of diseases rates among children in Hungary found that childhood diabetes incidence almost tripled in the two decades between 1978 and 1997, with the highest increase having been among the very young, (8f1) those most directly affected by the major increases in breastfeeding. Note, in the pale blue trend line above, that Hungary's breastfeeding rate also tripled between 1980 and 1996.
But there is much more. Note that Hungary's breastfeeding rates up until 1996 would have been the relevant rates for most of the period (1978-1997) during which the country's diabetes incidence tripled. (First diagnoses of childhood diabetes peak at about puberty, but they start occurring in infancy.) As substantial as the pre-1996 increases in breastfeeding were, notice that for a different period (1990 and later), the increases were even more rapid. Then note that the annual increase of Hungary's childhood diabetes incidence for the earlier period was 3.6%, as compared with 5.3% after 1998. (8f1a)
Something else that is noteworthy when comparing these sets of data: There was a "peak" of childhood diabetes incidence in Hungary in 2004, "mainly because of the unexpectedly high number of new cases observed in the 5-9-year old males." And that 2004 peak "...was followed by stable rates for a number of years." (8f1a) Notice in Figure 6 above how accurately that 2004 peak and stable period followed after the 1997 peak and subsequent flattening in the breastfeeding rate, with a lag that accurately fits the age range of those for whom the diabetes increase and subsequent stability was greatest.
The following is also of note when looking at the upper part of Hungary's breastfeeding trend line in Figure 6, specifically the spike in the breastfeeding rate in 2004-2005: among the age group most closely affected by that rapid increase (the 0-4-year-olds), childhood diabetes incidence increased from 8.9 to 14.1 per 100,000 in the period 2004-2009 (Table 4 of (8f1a)); those are the years that could have reflected that sharp 2004-2005 breastfeeding increase, for that age group. That compares with an increase of 17% for that age group in the earlier period, 1999-2003. (That earlier period would have mainly reflected the 6% increase in breastfeeding shown for the years between 1997 and 2003, with a minor effect from the earlier major increase.) So we see a four-fold difference in recorded increases in childhood diabetes when comparing two different periods, one of which followed a very rapid increase in breastfeeding and the other of which followed a period of mainly mild increase.
Section 2.c: More specifics about Europe as a whole:
As indicated earlier, the three Scandinavian countries, Finland, Norway and Sweden, had not only the clearly highest positions in Europe's breastfeeding rates but also the clearly highest rates of childhood diabetes; their specific rates were 30.3, 20.8 and 24.9 (mean incidence per 100,000), in the time period covered by the left half of the above chart.(data from Table 1 of 8d) The average of those incidences, at 25.3, should be compared with the 9.2 average childhood diabetes incidence (in that period) of the countries with the lowest breastfeeding rates (Greece – 9.7 &6.2, Malta – 14.7, France – 8.0, Belgium – 11.8, Austria in that period – 9.5, Hungary in that period – 6.1, Poland – 5.1, Luxembourg - 11.9, Estonia – 10.2, Latvia – 7.2, and Czech Republic – 9.8) (data from Table 1 of 8f3 and Table 1 of 8d)
To enlarge the comparison group near the high end,
a) Denmark can be added. Although very limited data appears to be available for that country's comparable, 6-month breastfeeding rates, what is available (see its data point at 1992 above) shows Denmark in fourth place in breastfeeding rates at that time; and the same diabetes data source used before (EuroDiab) shows Denmark significantly behind the three highest-breastfeeding countries in childhood diabetes, at 16.8 per 100,000, and still well above the low-breastfeeding countries.
b) Hungary, which helped complete the low-breastfeeding/low-diabetes group in the earlier part of these decades, had made a transition to both much higher breastfeeding and much higher diabetes by the 2000's. Diabetes data is not yet available reflecting the very latest stage of the transition, but what information is available shows an incidence of 18.8 per 100,000 for the 2004-2009 period, (8f1a) which places Hungary's childhood diabetes incidence within reach of the incidences of the highest-breastfeeding/highest-diabetes countries, and far above those of the low-breastfeeding countries. Note that most of the children whose diabetes is recorded in that figure had gone through their infancies before the period of the latest increase in breastfeeding, which came after 2004; therefore the rate of 18.8, still less than that of the Scandinavian countries, does not yet reflect the effects of Hungary's latest increases in breastfeeding.
c) Austria was also part of the low-breastfeeding/low-diabetes group at the left end of the chart, and it similarly made a transition to much higher breastfeeding and much higher childhood diabetes incidence. That incidence increased nearly three-fold just in the years between 1989-1991 and 2001-2005,(8c) commensurate with the increase of Austria's breastfeeding rate.
There are few countries in the intermediate range for which both diabetes and breastfeeding data are available, and what data is available is typically only partial for each country, so discussion of that would require more space than is justifiable. But it is noteworthy how consistently one can generalize regarding the countries with both high and low breastfeeding rates, including the same countries at different times, to the effect that high breastfeeding rates mean high childhood diabetes rates, and low breastfeeding rates mean low childhood diabetes rates.
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Section 2.d: Correlating increases, plateaus, and one decline in both breastfeeding and diabetes
Extraordinary increases in both breastfeeding and childhood diabetes in Hungary, Armenia and Austria were just discussed in Section 2.c, including above and below Figure 6. Poland: Very little long-term breastfeeding data was available for Poland in the charts shown earlier, but another WHO source shows a huge increase by one standard, as follows: "...exclusive breastfeeding rate under 4 months -- Poland has increased from 1.5% in 1988 to 17% in 1995".(8za) In what might be something other than coincidence, Poland also showed a huge (2½-fold) increase in childhood diabetes in one decade, a decade that would have been affected by the rapidly increasing breastfeeding during that 1988-1995 period, as follows: between 1989-1993 and 1999-2003, Poland's rate of growth in childhood diabetes was the very highest in the complete list of data for 17 countries and 3 U.K. regions that was compiled by the EURODIAB Study Group.(8f2)
Plateaus following increases: Section 2.a described increases in breastfeeding and diabetes that occurred in Sweden, Finland and Norway, following major increases in breastfeeding rates. But more notable were the diabetes plateaus (in Sweden and Norway) and sharp reduction in growth (in Finland) that followed flat or mildly declining periods in breastfeeding rates in those countries. Section 2.b told of a multi-year stable period in diabetes rates among 5-to-9-year-olds in Hungary accurately following a relatively stable period in that group's breastfeeding rate; again, the stable periods in both breastfeeding and diabetes were in contrast with major correlating increases that occurred in both breastfeeding and diabetes. Also in that section, the quotation from Armenia's endocrinologist describes a relatively sharp increase in childhood diabetes rates followed by a new, somewhat stable but fluctuating, much higher level; such a pattern of sharp increase followed by a fluctuating high level resembles the changing breastfeeding rate of Armenia as shown in Figure 6.
Decline: See Section 4 about the only world region in which childhood diabetes has been found to have declined, which also happened to have been the only world region in which breastfeeding has substantially declined.
After 1995: As indicated in Figure 5 and also in Figure 3, trends after 1995 in breastfeeding in countries other than Central and Eastern Europe discussed in this paper have been mixed and have not shown a steep average increase since 1995 similar to that of the CEE/CIS countries. And, perhaps not by pure chance, the average increases in childhood diabetes in those other countries for that period have also been far below those of the central and eastern European countries. The two studies of childhood diabetes in Europe (referenced above) pointed out the exceptional nature of the increases in childhood diabetes in central and eastern Europe. The authors of the 1989-2003 study provide no explanation for the fact that this extraordinary development was limited to this particular region and age group, beyond referring to "several hypotheses... that have pointed to modern lifestyle habits (referring to presumably altered lifestyles in the post-Soviet era) as possible environmental factors.... (including) reduced frequency of early infections." (See Section 3 regarding probable harm caused by reduced early infections.)
There is insufficient reliable data available for discussion of Romania.
Romania, as seen in breastfeeding rates reported in Figure 7, appears not to have been following the general upward trend (at least for the period reported on), so its reported increasing diabetes rate might seem to be an exception to the general correlation between breastfeeding and childhood diabetes rates. But there are good reasons to doubt the data for Romania as shown on that chart: (1) In a 2003 EU report, "Protection, promotion and support of breastfeeding in Europe," the table showing breastfeeding rates for 29 countries showed only one country for which it had to report, "No information available." That country was Romania. Conducting surveys on a topic such as breastfeeding is expensive and considered by some to be personally intrusive, and it appears that funds were not made available for that purpose in Romania before 2003. When somebody in Romania's Department of Health received the request from WHO for the country's breastfeeding rates, it is likely that the official had an assistant carry out a quick, informal poll among associates in the capital city and provided figures such as shown in Figure 7, which figures may have had little relation to what was actually going on in the country as a whole. Reinforcing the lack of actual surveying that would have gone into those WHO figures, a 2009 "European Nutrition and Health Report" provided four separate tables of different types of breastfeeding rates and trends, and there were only two countries for which there was no information for any of those four tables; one of those two countries providing no information was Romania. So when one sees that some data was provided to a third research organization but not to two others, one might wonder about how that data was arrived at.
Section 2.e: A disadvantage of being in cold, northern latitudes?
A hypothesis has been proposed to the effect that low sun exposure and/or cold temperatures in latitudes closer to the poles may contribute to the high diabetes rates in the Scandinavian countries. But that idea is contradicted by more examples than support it:
a) Notice Estonia and Latvia in Figure 7 and accompanying data, both of which are at about the same latitude as the Scandinavian countries and close to them geographically, but with childhood diabetes incidences averaging roughly a little over one-third as high; note that they also have low rather than high breastfeeding rates.
b) Lithuania is another neighbor at that same latitude. In a 2010 study of Lithuania and its neighbor countries of Finland, Sweden and Norway, it was found that they all have essentially identical genetic risk for type 1 diabetes.(8g2) Yet Lithuania's rate of childhood diabetes was reported to be one-fifth that of neighboring Sweden, a third of that of Norway, and one-seventh that of Finland.(8g3) Note Lithuania's relatively low position in the breastfeeding rates chart above.
c) Karelia is an essentially ethnically-identical neighbor of Finland, as well as at the same latitude, yet its diabetes rate (overall diabetes in this case, not just childhood diabetes) is reported to be one-sixth as high as that in Finland. (8g) Note that Karelia is one of the former Soviet lands, where, as mentioned in Section 2.b, breastfeeding was discouraged.
d) The case of Sardinia, a large island off Italy, is another example contradicting a connection between northern latitude and high childhood diabetes, since it has a very high incidence of that disease despite a very southern location. In that regard, it is worth noting that Sardinia's breastfeeding rate is the highest in Italy, (8h) prolonged breastfeeding is common in Sardinia,(8ha) and there was an anti-malaria campaign in Sardinia that resulted in considerable spraying of DDT; environmental toxins such as DDT are known to become concentrated in breast milk. (see www.breastfeeding-toxins.info) Liguria, a province in Northern Italy (but still very southern), has a childhood diabetes rate reported by a study group to approach those of the Scandinavian countries and Sardinia, (8hc) and it also has unusually high breastfeeding rates; breastfeeding at 24 weeks (almost 6 months) was found to be 54.4% in a 2008 study, which places it among the higher rates shown in Figure 7. (8hb)
e) Austria is also relatively southern (it borders on Northern Italy) and it has had a high childhood diabetes rate -- but only following its transition to a high breastfeeding rate. (See "Austria" in Section 2.a)
The lowest incidence of childhood type 1 diabetes in Europe has been reported from Macedonia.(8y) It is relevant to note that exclusive breastfeeding in Macedonia is also very unusually low, very likely the lowest in Europe, as indicated in a report by the Macedonian government: "About 40 percent of infants aged 0-1 months are exclusively breastfed, and this proportion drops rapidly until it is close to zero by four months." (8z) When trying to see how that compares with other European countries, comparable exclusive breastfeeding data for other European countries appears not to be available; but information regarding breastfeeding rates in the U.S. sheds considerable light, as follows:
a) The U.S. is near the low end in a chart of non-exclusive breastfeeding rates in OECD (mostly European) countries (see chart below):
b) the U.S. has an exclusive breastfeeding rate at six months of about 14% (see far bottom right corner of Figure 1), compared with Macedonia’s rate of close to zero, at four months.
Since Macedonia has an exclusive breastfeeding rate that is very far below that of a country that itself ranks near the low end of international breastfeeding rates, it is probable that Macedonia's breastfeeding is at (or at least very near) the lowest level in all of Europe. This should be seen in relation to the fact that Macedonia also has the lowest level of childhood type 1 diabetes in Europe.
Section 3: Biological / scientific reasons for seeing a relationship between breastfeeding and diabetes
It should be pointed out that diabetes type 1 is basically an autoimmune disease. Picking up on the well-established hypothesis (mentioned in the quote just above) about reduced early infections' being a possible cause of the rapid increases in diabetes among the very young: It should be explained that the specific mechanism of the suspected harm is reduction of microbial challenges that would otherwise stimulate development of the immune system (more on this below). There is also authoritative scientific evidence about other probable harm caused by breastfeeding to the developing immune system (direct toxicity, not merely deprivation of microbial exposure), as will be described later.
It is well-known and not disputed that immune cells from the mother are transmitted to an infant in breast milk, and that is clearly helpful to an infant in areas with poor sanitation. But in developed countries, the benefits of those immune cells are very much in question. A web page of the U.S. Food and Drug Administration favorably presents a line of reasoning according to which proper infant development depends on “the necessary exposure to germs required to “educate” the immune system.... In the period immediately after birth the child’s own immune system must take over and learn how to fend for itself.” The FDA reports that this “hygiene hypothesis” is supported by epidemiological studies. A prominent doctor uses stronger language, describing the “critical importance of proper immune conditioning by microbes during the earliest periods of life.” A study found on the NIH’s website discusses “the microbial exposure which may be critical for immune priming” and suggests it would be helpful to re-name the “hygiene hypothesis” as “microbial deprivation hypothesis.” (9) According to the UCLA Food and Drug Allergy Care Center, "Overwhelming evidence from various studies suggests that the hygiene hypothesis explains most of the allergy epidemic."(9a) (Note that allergies, like diabetes, result from malfunction in the immune system.) Given the above, there are strong reasons to question whether breastfeeding's transmission of externally-sourced immune cells to an infant, and the resulting reduction in exposure to everyday microbes (below the already historically low levels in developed countries), is anything but harmful to a child's long-term health.
In addition to the above-suggested indirect effect of breast milk on development of the immune system, there are other relevant harmful direct effects resulting from toxins known to be contained in breast milk. According to an extensive 2011 study on environmental toxicants and the developing immune system, toxins including dioxins, PCBs, PAHs, BPA, and phthalates can harm development of the immune system.(10) Associations have been reported between diabetes and both PCBs and dioxins at levels of exposure seen in the U.S. population.10a
Note that all of these toxins have been found in breast milk, with dioxins in doses known to be especially high in relation to the EPA-determined safe level. Moreover, in the only comparisons that can be readily found, the doses of these toxins in human milk have been found to be many times higher than those in cow's milk or infant formula. Extensive evidence for the above statements from the EPA and other trustworthy sources can be found at http://www.breastfeeding-toxins.info/, Section 2.
According to a report prepared for the Danish Health and Medicines Authority “dozens of studies have linked PCB exposure to the metabolic syndrome, insulin insensitivity and changes in insulin secretion. One study reported that the women with the highest 20% of the blood-PCB concentrations had a 3-fold increased risk of type-2 diabetes.”(11) Knowing that, note that in an American study, in 4-year-old children, body burden of PCBs in children breastfed for at least 6 months was found to be about 17 times as high as the burdens of those who had not been breast-fed (5.1 vs. 0.3 ng/ml)(12)
Aside from the many geographical and chronological correlations of diabetes with breastfeeding, a number of scientific studies have also pointed out such correlations, especially with type 1 diabetes (often referred to as IDDM, or insulin-dependent diabetes mellitus). In a 1995 study of 293 children in Colorado, it was found that children with an early predictor of type 1 diabetes had been breastfed for an average of 10 months, compared with an average of 8 months for the controls. (8k) Similar results were found in a study of 52 diabetic cases and 52 well-matched controls in Iran: "A large (sic) proportion of the diabetic children rather than the control children had been breast-fed, and the risk of IDDM among children who had not been breast-fed was below unity." ("below unity" = below average risk) (8l) Similar results were also found in a study of 100 diabetic children and 100 controls in Italy in 1997: The diabetic subjects had been breastfed for an average of 3 months vs. an average of 2 months for the controls. (8m) In a Finnish study, of 6200 children born in 1994-95 with follow-up in 2006, it was found that "early regular daily feeding with cow's milk-based formula tended to associate with lower risk for type 1 diabetes (OR 0.66; 95% confidence interval 0.38-1.13; P = 0.08)." (8n) In a 1990-91 study of 55 patients and 181 controls at two Ethiopian-Swedish hospitals, it was found that "introduction of bottle-feeding was significantly more frequent among unrelated controls at three months of age (9/39 diabetics versus 41/83 controls)." That is, they found that unrelated non-diabetics were over twice as likely to have been bottle-fed at three months of age as were the diabetics. (8o) In a study in Venezuela, of 40 diabetic children and 40 age, sex and race-matched controls, it was found that for "95% of controls vs 65% of IDDM (p<.001), cow's milk was given exclusively from birth, or combined with breastfeeding…;" (8x) in other words, it appears that 35% of diabetic children had received only human milk after birth, compared with only 5% of the non-diabetic children. In a study of 100 children in Sardinia (a large island off the Italian peninsula) diagnosed with diabetes between 1983 and 1994, it was found that "a larger proportion of the diabetic children rather than the control children had been breast-fed, and the risk of IDDM among children who had not been breast-fed was below unity (odds ratio [OR] 0.41; 95% CI 0.19–0.91)." (8p) (In other words, a bottle-fed infant's risk of becoming diabetic was 41% as high as that of a breastfed infant.)
Section 4: An outstanding exception to the world trend in childhood diabetes, this time at the low end, which is also an outstanding exception to the world trend in breastfeeding rates, also at the low end:
Bear in mind what was found at the high end of the generally-increasing diabetes rates (described in Section 2.b): the same region (central and eastern Europe) that had exceptionally high increases in childhood diabetes also had had what were apparently by far the world's greatest increases in breastfeeding rates. Then observe what has happened at the low end of both of these categories, again in one particular region (the same region) in both cases, as follows:
Information about childhood diabetes provided by the DiaMond (Diabetes Mondiale) Project Group, from the period 1990-1999, includes the following: "The trends estimated for continents showed statistically significant increases all over the world..., except in Central America and the West Indies where the trend was a decrease of 3.6%." (8s) Beyond mentioning this exception, the Diamond group attempted no explanation as to what should be different in this region as compared with the rest of the world. Regarding an environmental factor that could be closely related, a U.N. web page provides information about declines in breastfeeding in this same region. Explaining what is underlying declines in breastfeeding in the region, which stand out from trends in the rest of the world (see Figures 3 and 5), the U.N. web page points out (in Section 3.2), "In Central and South America and the Caribbean there is renewed interest in the role that processed complementary foods can play in providing a nutritionally complete infant and toddler food." (8w) The U.N. web page specifically mentions Guatemala and Dominican Republic as countries in this regions in which breastfeeding had been declining, showing a decline from 8.4 to 5.9 months for median duration of breastfeeding for the latter country between 1986 and 1991. Breastfeeding rates (exclusive, less than 6 months) are also reported to have declined in the following other Central American and West Indies countries: Honduras - - 34.9 to 29.7 (2001 to 2006); Nicaragua – 31.1 to 30.6 (2001 to 2007); Costa Rica – 35 to 15.3 (1993 to 2006); Cuba – 41.2 to 26.4 (2000 to 2006); Belize – 24 to 10.2 (1999 to 2006); Mexico, although typically considered part of North America, could logically be grouped together with its Latin sister countries in Central America; Mexico's 0-5 month exclusive breastfeeding percentage went from 38% in 1987 to 20% in 1999. Data that permits comparisons of equivalent breastfeeding rates over time in this region is limited; aside from the decreases indicated above for 7-8 countries of this region, only for El Salvador and Haiti does available information indicate anything other than a decline in breastfeeding.(8wa) Notice that most of the declines reported were substantial.
It is worth emphasizing, from what was presented above, that there was apparently only one region in the world in which childhood diabetes had been decreasing; and there was also apparently only one region in the world in which breastfeeding rates had been significantly decreasing. In both cases, that "only region in the world" was the same region. Notice that this follows the same pattern noted earlier (Section 2.b): there was one region in the world in which childhood diabetes had increased exceptionally, and that was also the region in which breastfeeding had also increased exceptionally.
Other international comparisons
Turkey. A study of 217,030 Turkish children, published in 2011, found the prevalence of type 1 diabetes among primary school children to be nearly triple the rate found in that age group in Ankara 16 years earlier. Another study in Turkey, published in 2010, found a 3.5-fold increase over approximately the same period in the same age group.(8z4) It is relevant to note that the percentage of infants under the age of 6 months who were breastfed in Turkey increased about six-fold between 1998 and 2008. (8z5)
According to the DiaMond Project Group, reporting on childhood diabetes incidence worldwide as of the 1990's, the age-adjusted incidence of type 1 diabetes was found to be at a world low of 0.1 per 100,000/year in Venezuela as well as China.(8s) It is of interest that Venezuela, with its world low in childhood diabetes, also appears to be essentially at the bottom level of the world's rates of exclusive breastfeeding, sharing that level only with several African countries and Suriname. And Venezuela's extremely low level in childhood diabetes is especially noteworthy in that the country's rate of diabetes among adults is at the very highest level in Latin America.(8v3)
The above is worth thinking about: Venezuela has very high risk for diabetes as indicated by incidence among its adult population. But diabetes incidence among its children is exceptionally low. Its rate of exclusive breastfeeding is also very exceptionally low. There are good reasons to see a biological link between human milk and diabetes (see Section 3), and there are also many other correlations between varying levels of breastfeeding and variations in diabetes incidence: see Section 2.b, Section 4 and elsewhere in this article.
It is worth looking at the other countries that also have extremely low breastfeeding rates:
a) The only non-African country for which UNICEF statistics showed exclusive breastfeeding rates to be as low as or lower than Venezuela was Suriname (Venezuela's neighbor).(8v1) It is noteworthy that Suriname shares Venezuela's position not only at the bottom level of the world's breastfeeding rates but also at the bottom level of the world's childhood diabetes incidence.(8v2)
b) Again according to UNICEF data showing the countries with the lowest exclusive breastfeeding rates in the world, the next country above Venezuela is the Dominican Republic. That country also has a childhood diabetes rate (according to the International Diabetes Federation) that is the fifth from the lowest in the world.
c) Just above Dominican Republic in the list of the Western Hemisphere's lowest-breastfeeding countries is the small Central American country, Belize, which has a childhood diabetes rate one fourteenth as high as that of the U.S.
See later in this section regarding China, at one time also at the world's bottom level in childhood diabetes, also having a very low level of breastfeeding in the period when its diabetes incidence was very low.
The age-adjusted incidence of Type 1 diabetes in China was reported to be one of the two lowest in the world in data from the early 1990's (8s) (although that has changed since then). It is relevant to note that breastfeeding rates in China had reached a low during the 1980's, and what breastfeeding was done was apparently typically supplemented from an early point, owing to traditions that went back as far as writings from a 6th-Century AD dynasty; two separate surveys in Beijing showed that breastfeeding at four months was about 16% in 1989-94. (8z2) In a rural area near Shanghai a survey found the "breastfeeding rate" to be 44.1% in the early 1990s and "the rates in urban areas were invariably lower." (8z2a) (The authors of the paper just quoted said that where the term "breastfeeding" is used without indication of duration or exclusivity, it is used to mean "any breastfeeding.") It is relevant to note that the 44%-and-less breastfeeding rate would fall at the extreme low end of the rates shown in Figure 9. So it appears that China's childhood diabetes incidence being one of the two or three lowest in the world as of the 1990's would have been very compatible with China's extremely low breastfeeding rates as of the early 1990's.
But following heavy promotion of breastfeeding by the Chinese government beginning in the early 1990's, breastfeeding rates in that country increased greatly, in some cases more than tripling, and reaching 80% at four months in most parts of China. (8z2) And childhood diabetes also increased greatly in that same period. A major study, published in 2012 and drawing from a 2009 survey, found that "in the past two decades" there were very large increases in overweight (often linked with diabetes) in Chinese children, and diabetes in 12-to-18-year-olds was determined to have become almost four times that in the same U.S. age group. (8z2a) That is a major reversal from its world-low level of childhood diabetes just two decades earlier, coinciding with its major transition away from a very low level of breastfeeding.
It is possible that the extent of the increases in breastfeeding in China (probably including exclusiveness as well as duration) was especially great because the Chinese government (which was heavily promoting breastfeeding) exercises tight control over its population.
International highs and lows in childhood diabetes have correlated well with highs and lows in breastfeeding rates. (Section 5)
Increases and decelerations in childhood diabetes rates have tracked accurately with increases and decelerations in breastfeeding rates in all reported (and readily found) cases of changing breastfeeding rates among nations; that included exceptionally high increases in an entire region. (see Sections 1 and 2 and parts of Section 5)
While childhood diabetes incidence and breastfeeding rates were apparently both increasing in most of the world, they were both declining in only one world region, which was the same region in both cases. (see Section 4)
Childhood diabetes incidence correlated well with the only readily-found instance of a particular ethnic group's breastfeeding rate changing especially rapidly (Section 1.b).
And there is excellent scientific evidence to explain why all of these increases, decelerations, decreases, highs and lows in breastfeeding and diabetes should correlate so closely, as found in Section 3.
When discussing some probable serious drawbacks of breastfeeding, one question that would logically come up is, "Isn't breastfeeding known to have some significant benefits for infants" That is a major separate question, which is dealt with at length at http://www.breastfeedingprosandcons.info/.
Comments on the above are invited, including criticisms if they are specific, and will usually receive a response. You can see our “Comments” section at www.pollutionaction.org/comments.htm. In criticisms, please point out any specific passages that you feel are not accurately based on authoritative sources (as cited) or that do not logically follow from the evidence presented. Note that the author of this article feels no obligation to present the pro-breastfeeding case as long as the medical associations do not present the anti-breastfeeding case. Please e-mail to email@example.com.
*As the author of the above, my role has not been to carry out original research, but instead it has been to read through very large amounts of scientific research that has already been completed on the subjects of environmental toxins and infant development, and then to summarize the relevant findings; my aim has been to put this information into a form that enables readers to make better-informed decisions related to these matters. The original research articles and government reports on this subject (my sources) are extremely numerous, often very lengthy, and are usually written in a form and stored in locations such that the general public is normally unable to learn from them.
My main qualification for writing these publications is ability to find and pull together large amounts of scientific evidence from authoritative sources and to condense the most significant parts into a form that is reasonably understandable to the general public and also sufficiently accurate as to be useful to interested professionals. My educational background included challenging courses in biology and chemistry in which I did very well, but at least as important has been an ability to correctly summarize in plain English large amounts of scientific material. I scored in the top one percent in standardized tests in high school, graduated cum laude from Oberlin College, and stood in the top third of my class at Harvard Business School.
There were important aspects of the business school case-study method that have been helpful in making my work more useful than much or most of what has been written on this subject, as follows: After carefully studying large amounts of printed matter on a subject, one is expected to come up with well-considered recommendations that can be defended against criticisms from all directions. The expected criticisms ingrain the habits of (a) maintaining accuracy in what one says, and (b) not making recommendations unless one can support them with good evidence and logical reasoning. Established policies receive little respect if they can’t be well supported as part of a free give-and-take of conflicting evidence and reasoning. That approach is especially relevant to the position statements on breastfeeding of the American Academy of Pediatrics and the American Academy of Family Physicians, which statements cite only evidence that has been
(a) selected, while in no way acknowledging the considerable contrary evidence and a1
(b) of a kind that has been authoritatively determined to be of low quality. Former U.S. Surgeon General Regina Benjamin acknowledged that essentially all of the research supporting benefits of breastfeeding consists merely of observational studies.a1a One determination that evidence from observational studies is of low quality has been provided by Dr. Gordon Guyatt and an international team of 14 associates;a2 Dr. Guyatt is chief editor of the American Medical Association’s Manual for Evidence-based Clinical Practice, in which 26 pages are devoted to examples of studies (most of which were observational) that were later refuted by high-quality studies.a2a A similar assessment of the low quality of evidence from observational studies has been provided by the other chief authority on medical evidence (Dr. David Sackett),a2c writing about “the disastrous inadequacy of lesser evidence,” in reference to findings from observational studies.a2b
When a brief summary of material that conflicts with their breastfeeding positions is repeatedly presented to the physicians’ associations, along with a question or two about the basis for their breastfeeding recommendations, those associations never respond. That says a great deal about how well their positions on breastfeeding can stand up to scrutiny.
The credibility of the contents of the above article is based on the authoritative sources that are referred to in the footnotes: The sources are mainly U.S. government health-related agencies and reputable academic researchers (typically highly-published authors) writing in peer-reviewed journals; those sources are essentially always referred to in footnotes that follow anything that is said in the text that is not common knowledge. In most cases a link is provided that allows easy referral to the original source(s) of the information. If there is not a working link, you can normally use your cursor to select a non-working link or the title of the document, then copy it (control - c usually does that), then “paste” it (control - v) into an open slot at the top of your browser, for taking you to the website where the original, authoritative source of the information can be found.
The reader is strongly encouraged to check the source(s) regarding anything he or she reads here that seems to be questionable, and to notify me of anything said in the text that does not seem to accurately represent what was said by the original source. Write to firstname.lastname@example.org. I will quickly correct anything found to be inaccurate.
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a1a) The Surgeon General’s Call to Action to Support Breastfeeding 2011, p. 33, at www.surgeongeneral.gov/library/calls/breastfeeding/calltoactiontosupportbreastfeeding.pdf
a2) Figure 2 in Guyatt et al., GRADE guidelines: 1. Introduction -- GRADE evidence profiles and summary of findings tables, Journal of Clinical Epidemiology, at http://www.jclinepi.com/article/S0895-4356(10)00330-6/pdf
a2a) Dr. Gordon Guyatt is chief editor of User’s Guides to the Medical Literature: A Manual for Evidence-based Clinical Practice, 2nd Edition (3rd is upcoming), copyright American Medical Association, published by McGraw Hill.
a2b) Writing in The Canadian Medical Association Journal, as quoted in “Do We Really Know What Makes Us Healthy?” New York Times, published: September 16, 2007 at http://www.nytimes.com/2007/09/16/magazine/16epidemiology-t.html?pagewanted=2&_r=0
a2c) In a review in the Journal of the Medical Library Association, only two guides are recommended for use by physicians in evaluating evidence in medical literature, one of which is the one edited by Guyatt et al., already referred to, and the other of which is by Dr. Sackett. (Journal of the Medical Library Association, Oct. 2002, User’s Guide to the Medical Literature: A Manual for Evidence-Based Clinical Practice, Review by Rebecca Graves, at httpi://www.ncbi.nlm.nih.gov/pmc/articles/PMC128970)
Some of the full articles below are available for free online, but to obtain the full text of some of these articles for free, you may have to visit a university library or ask at the reference desk at your local public library.
(1) "Breastfeeding, Family Physicians Supporting (Position Paper)" -- AAFP Policies -- American Academy of Family Physicians
(2) "Surgeon General's Call to Action to Support Breastfeeding, 2011," p. 33 at http://www.surgeongeneral.gov/library/calls/breastfeeding/calltoactiontosupportbreastfeeding.pdf
(2a) Arenz S, Ruckerl R, Koletzko B, von Kries R. "Breast-feeding and childhood obesity—a systematic review." Int J Obes Relat Metab Disord 2004;28:1247–1256.
(3) Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, "Systems to Rate the Strength of Scientific Evidence, Evidence Report/Technology Assessment: Number 47" http://archive.ahrq.gov/clinic/epcsums/strengthsum.pdf
(3a) A History of Infant Feeding J Perinat Educ. 2009 Spring; 18(2): 32–39. doi: 10.1624/105812409X426314 PMCID: PMC2684040 Emily E Stevens, et al., at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684040/
(5) "Diabetes in Children and Teens," Medline Plus, U.S. National Library of Medicine, NIH at http://www.nlm.nih.gov/medlineplus/diabetesinchildrenandteens.html Also see Medline Plus Weekly Digest Bulletin, 11/25/2012 at http://www.nlm.nih.gov/medlineplus/news/fullstory_131557.html
(6) Type 2 Diabetes in Children and Young Adults: A “New Epidemic” Francine Ratner Kaufman, MD CLINICAL DIABETES • Volume 20, Number 4, 2002 at http://clinical.diabetesjournals.org/content/20/4/217.full.pdf+html Also see footnote 7b below. Also, a Univ. of Michigan article published in 2008 reported, “Recent studies suggest that there have been dramatic increases in type 2 diabetes among individuals in their 20s and 30s...." (at http://www2.med.umich.edu/prmc/media/newsroom/details.cfm?ID=422), which is compatible with origins of the epidemic in infant development after 1972.
(7) "Breastfeeding in the United States: Findings from the National Health and Nutrition Examination Survey, 1999-2006"
(7a) http://care.diabetesjournals.org/content/24/2/412.1/T1.large.jpg ; also note the 2002 comment by the president of the American Diabetes Association.
(7b) Trends in Hospitalizations for Diabetes Among Children and Young Adults United States, 1993–2004 JOYCE M. LEE et al., at http://care.diabetesjournals.org/content/30/12/3035.full.pdf+html
(7c) Table 27 of CDC's Health, United States, 2011 http://www.cdc.gov/nchs/data/hus/hus11.pdf#listtables
(7d) American Diabetes Assn., Diabetes, The Rise of Childhood Type 1 Diabetes in the 20th Century, Edwin A.M. Gale, Department of Diabetes and Metabolism, Division of Medicine, University of Bristol, U.K
(7e) CDC’s Health United States 2013, at http://www.cdc.gov/nchs/data/hus/hus13.pdf#046, Table 46. Diabetes prevalence and glycemic control among adults aged 20 and over, by sex, age, and race and Hispanic origin: United States, selected years 1988–1994 through 2007–2010. In the “Age” section at bottom of p. 1, the percent of total cases was found to rise from 2.6 to 3.4 for the 20-44 age category, and from 13.9 to 15 percent in the 45-64 age group during the two decades after 1988, with even greater differences in a 1½-decade interval.. Data about glycemic control is on page 2 of the chart.
(7f) accessed at www.ucdenver.edu/academics/colleges/medicalschool/centers/BarbaraDavis/Documents/book-Type1DiabetesHTML/type1_ch9.html See also Table 9.1.
(8) For Norway, Sweden and Finland, the average incidence is 42.1. The average incidence for the low-breastfeeding countries (U.K., France, Poland and Ireland) is 16.5. (no data for Belgium) For Poland, the only low-breastfeeding country not shown on the breastfeeding chart, information is available from WHO, Nutrition Data Banks, Global Data Bank on Breastfeeding, as follows: "...exclusive breastfeeding rate under 4 months -- Poland has increased from 1.5% in 1988 to 17% in 1995"; by comparison, from the same source, Sweden increased from 55% in 1992 to 61% in 1993. Above found at https://apps.who.int/nut/db_bfd.htm Poland's breastfeeding rates increased considerably over the following 15 years, but, after such a low start, its average breastfeeding rate for the relevant period would almost certainly still be in the lower category.
(8a) Joner G, Søvik O: Increasing incidence of diabetes mellitus in Norwegian children 0-14 years of age 1973-1982. Diabetologia 32 :79 -83,1989
(8b) Joner G, Stene LC, Søvik O: No increase in incidence of type I diabetes in young children in Norway 1989-1998 (Abstract). Diabetologia 43 (Suppl. 1) :A27 ,2000
(8c) Perinatal risk factors for early childhood onset type 1 diabetes in Austria – a population-based study (1989–2005) Thomas Waldhoer et al. DOI: 10.1111/j.1399-5448.2008.00378.x 2008 Pediatric Diabetes Volume 9, Issue 3pt1, pages 178–181, June 2008 at http://onlinelibrary.wiley.com/doi/10.1111/j.1399-5448.2008.00378.x/abstract. There were three intermediate readings helping to verify a linear upward trend over the period discussed.
(8c1) Donor Milk Banking and Breastfeeding in Norway, Grovslien et al., J Hum Lact 2009 25: 206
The online version of this article can be found at http://jhl.sagepub.com/content/25/2/206
(8d) Worldwide increase in incidence of Type I diabetes – the analysis of the data on published incidence trends, Onkamo et al., Diabetologia (1999) 42: 1395-1403
(8e) Cold Spring Harb Perspect Med 2012. 2: 2012 The Pathogenesis and Natural History of Type 1 Diabetes Mark A. Atkinson: http://perspectivesinmedicine.org/content/2/11/a007641.full
(8e2a) Time trends in the incidence of type 1 diabetes in Finnish children: a cohort study Table 1 Valma Harjutsalo, et al., Diabetes Unit, Department of Health Promotion and Chronic Disease Prevention, National Public Health Institute, Helsinki, Finland Lancet 2008; 371: 1777–82
(8e3) Lancet. 2008 May 24;371(9626):1777-82. doi: 10.1016/S0140-6736(08)60765-5. Time trends in the incidence of type 1 diabetes in Finnish children: a cohort study. Harjutsalo V, et al.,Diabetes Unit, Department of Health Promotion and Chronic Disease Prevention, National Public Health Institute, Helsinki, Finland.
(8f) See endnote (8d) above; also http://www.medscape.com/viewarticle/445672_6 and also: Diabetologia (2001) 44 (Suppl 3) B3-B8 at http://www.researchgate.net/publication/225171856_Trends_in_the_incidence_of_childhood-onset_diabetes_in_Europe_19891998 and also EURODIAB ACE Study Group: Variation and trends in incidence of childhood diabetes in Europe. Lancet 355 :873 -876,2000
(8fa) Regarding low exclusive breastfeeding in the Soviet era, and the subsequent increases, “The medical school curriculum in all Soviet countries taught physicians that mothers must complement breastmilk with vegetable and fruit juices," according to Kim Hekimian, an Armenian and lecturer at the Institute of Human Nutrition at Columbia University and visiting professor at the American University of Armenia, quoted in "Undernutrition in Armenia: A Matter of National Security." Posted by Nanore Barsoumian on July 19, 2012 in "Armenia, Special Reports," of The Armenian Weekly. At http://www.armenianweekly.com/2012/07/19/undernutrition-in-armenia-a-matter-of-national-security/ She also adds, “There was an incredibly successful coordination of strategic intervention (promoting breastfeeding) for four years in Armenia, paid for by USAID and UNICEF,” she explained. “[It included] a social marketing campaign that involved TV, radio, brochures, and newspapers. They also paid for the in-service retraining of all pediatricians, Ob/Gyns [obstetricians, gynecologists], and most nurses in the field.” They also changed the medical school curriculum on breastfeeding, and related policies at the Ministry of Health. ” From another source, "During Soviet time immediate initiation (of breastfeeding) after delivery was prohibited.... Before 1993 exclusive breastfeeding was almost non existent. Infant formula was freely distributed in delivery hospitals...," from Armenian Case Study, presented by Confidence Health, NGO – member of IBFAN, by Susanna Harutyunyan found atwww.ennonline.net/pool/files/ife/armenian-case-study.doc. From another source, "As a member of the Soviet Union, the Republic of Kazakhstan adopted a national policy encouraging mothers to use artificial foods in lieu of breastfeeding to enable mothers to return to the workforce soon after giving birth. This practice of lactation management, used in Kazakhstan and in other republics of the former USSR, separated newborn infants from their mothers in maternity wards.... the program promoted supplementary feedings of a boiled water and glucose formula during the first days of infancy and advocated substantial supplementary feeding in the first or second months after delivery." (from Promotion of Lactation Amenorrhea Method Intervention Trial, Kazakhstan Academy of Preventive Medicine, Republic of Kazakhstan Shamil Tazhibayev, MD, et al; italics added: at http://pdf.usaid.gov/pdf_docs/PNACX991.pdf) Data verifying the low levels of breastfeeding in former Soviet states, especially before major increases took place, can also be found in Feeding and Nutrition of Infants and Young Children, Guidelines for the WHO European Region, with emphasis on the former Soviet countries, Kim Fleischer Michaelson et al., WHO Europe and UNICEF, Chapter 1, p. 30
(8f1) Orv Hetil. 1999 May 16;140(20):1107-11. Incidence of type 1 childhood diabetes in Hungary (1978-1997). Hungarian Committee on the Epidemiology of Childhood Diabetes Gyürüs E, et al., abstract at http://www.ncbi.nlm.nih.gov/pubmed/10377741. Also "Constantly rising or peaks and plateaus?" Incidence of childhood type 1 diabetes in Hungary (1989-2009)].Gyürüs E, et al. 7. 7623. Orv Hetil. 2011 Oct 16;152(42):1692-7. doi:10.1556/OH.2011.29210. Abstract Also Twenty-one years of prospective incidence of childhood type 1 diabetes in Hungary--the rising trend continues (or peaks and highlands?). Pediatr Diabetes. 2012 Feb;13(1):21-5. doi: 10.1111/j.1399-5448.2011.00826.x. Epub 2011 Nov 8. Gyurus EK et al. Also, for information about greatest increase among youngest children, see Pediatr Diabetes. 2002 Dec;3(4):194-9, Dynamic changes in the trends in incidence of type 1 diabetes in children in Hungary (1978-98), Gyürüs E, et al. For increases in another CEE country, Poland, see Incidence trends for childhood type 1 diabetes in Europe during 1989–2003 and predicted new cases 2005–20: a multicentre prospective registration study. Patterson CC, et al., the EURODIAB Study Group. Lancet 2009: 373: 2027–2033.
(8f1a) Epidemiology Of Type 1 Diabetes In Children In Hungary, Éva K Gyürüs, MD, University of Pécs, with Gyula Soltész MD, PhD, DSc, 2011. V.1.1, p. 52 for incidence rates in different periods; at http://aok.pte.hu/docs/phd/file/dolgozatok/2012/Gyurus_Eva_PhD_dolgozat.pdf
(8f2) Incidence trends for childhood type 1 diabetes in Europe during 1989-2003 and predicted new cases 2005-20: a multicentre prospective registration study CF Patterson et al., www.thelancet.com, Vol 373, June 13, 2009
(8f2a) There are good reasons to question the data shown by WHO for Romania. In a 2003 EU report, "Protection, promotion and support of breastfeeding in Europe," the table showing breastfeeding rates for 29 countries showed only one country for which it had to report, "No information available," and that country was Romania. Also, a 2009 University of Vienna "European Nutrition and Health Report" (European Nutrition and Health Report 2009, Volume Editor Ibrahim Elmadfa Vienna, Karger (Pub.) at http://www.univie.ac.at/enhr/downloads/enhrii_book.pdf) provided four separate tables with different types of breastfeeding rates and trends, and there were only two countries for which there was no information for any of those four tables; one of those two countries providing no information was Romania. Conducting surveys on a topic such as breastfeeding is expensive and probably considered by some to be personally intrusive, and it appears that funds were not made available for that purpose in Romania before 2003. When somebody in Romania's Department of Health received the request from WHO for the country's breastfeeding rates, it is likely that the official assigned the task had an assistant carry out an informal polling among associates in the capital city and provided figures that may have had little relation to what was actually going on in the country as a whole. So when one sees that some data was provided to a third research organization but not to two others, one might wonder about how the provided data was arrived at. Instead of the early 6-month breastfeeding rate shown for Romania by WHO, which was twice as high as the average for Central and Eastern Europe at that time and far higher than that of any other CEE country, it is probable that its rate actually fit within the general parameters for its region. As of 2005, there is more credible data available for Romania (see Figure 9), showing a breastfeeding rate about 1% lower than that of high-breastfeeding Finland at that time. So Romania is probably one of the countries that, like Hungary, Austria, and Armenia, went through a major transition from low breastfeeding to high breastfeeding.
(8f3) Trends in the incidence of childhood-onset diabetes in Europe 1989-1998, A Green, CC Patterson on behalf of the EUROLAB TIGER Study Group, Diabetologia (2001) 44 (Suppl 3) B3-B8
(8g) The ‘hygiene hypothesis’ for autoimmune and allergic diseases: an update H Okada, et al., Clinical and Experimental Immunology, 2010 April; 160(1): 1–9. doi: 10.1111/j.1365-2249.2010.04139.x PMCID: PMC2841828 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841828/
(8g2) HLA class II alleles and haplotypes in Lithuanian children with type 1 diabetes and healthy children (HLA and type 1 diabetes), Erika Skodeniene, et al., Institute of Enndocrinology, Kaunas University of Medicine. Medicina (Kaunas 2010; 46(8)
(8g3) Diabetes in the Young: a Global Perspective Global trends in childhood type 1 diabetes Gyula Soltesz et al., Department of Pediatrics, University of Pecs, Hungary, IDF Diabetes Atlas fourth edition, at http://www.idf.org/sites/default/files/Diabetes_in_the_Young.pdf
(8h) Espr European Society For Pediatric Research Siena, Italy August 31, 2005 – September 3, 2005 Pediatric Research (2005) 58, 358–358; Breastfeeding Across Geographical Areas in Italy M Giovannini et al.
(8ha) J Aging Res. 2011; 2011: 153756. Published online 2011 October 25. doi: 10.4061/2011/153756 PMCID: PMC3205712 A Population Where Men Live As Long As Women: Villagrande Strisaili, Sardinia Michel Poulain, et al.
(8hb) Acta Paediatr. 2008 May;97(5):613-9. doi: 10.1111/j.1651-2227.2008.00711.x. Epub 2008 Mar 28. Breastfeeding in Northern Italy. Santini P, et al. at http://www.ncbi.nlm.nih.gov/pubmed/18373720
(8hc) Diabetes Care. 2003 Jun;26(6):1786-9. High incidence of childhood type 1 diabetes in Liguria, Italy, from 1989 to 1998. Cotellessa M at http://www.ncbi.nlm.nih.gov/pubmed/12766110
(8i) The Rise of Childhood Type 1 Diabetes in the 20th Century, Edwin A.M. Gale, Diabetes. 2002; 51(12) at http://www.medscape.com/viewarticle/445672
(8k) Lack of association between early exposure to cow's milk protein and beta-cell autoimmunity. Diabetes Autoimmunity Study in the Young (DAISY) Norris JM et al., JAMA. 1996 Aug 28;276(8):609-14.
(8l) Indian J Pediatr. 2001 Feb;68(2):107-10. IDDM and early exposure of infant to cow's milk and solid food. Esfarjani F et al., National Nutrition and Food Technology Research Institute, Shaheed Beheshti University, Tehran, IR, Iran.
(8m) IDDM and early infant feeding. Sardinian case-control study. Meloni T et al., Diabetes Care. 1997 Mar;20(3):340-2. Istituto di Clinica Pediatrica e Neonatologica, University of Sassar, Italy.
(8n) Early infant feeding and type 1 diabetes. Savilahti E et al., Eur J Nutr. 2009 Jun;48(4):243-9. doi: 10.1007/s00394-009-0008-z. Epub 2009 Mar 5. Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
(8o) The relation of early nutrition, infections and socio-economic factors to the development of childhood diabetes. Telahun M et al., Department of Paediatrics and Child Health, Faculty of Medicine, Addis Abeba University. Ethiop Med J. 1994 Oct;32(4):239-44.
(8p) IDDM and Early Infant Feeding: Sardinian case-control study Tullio Meloni, MD (+5 other MDs and one PhD) Istituto di Clinica Pediatrica e Neonatologica, University of Sassari Sassari American Diabetes Assn., Diabetes Care, Copyright © 1997 by the American Diabetes Association
(8r) Raphael, D., ed., Breastfeeding and food policy in a hungry world. New York, Academic Press, 1979. p. 75-79.
(8s) Incidence and trends of childhood Type 1 diabetes worldwide 1990-1999. DIAMOND Project Group. Diabet Med. 2006 Aug;23(8):857-66. At https://pubmed.ncbi.nlm.nih.gov/16911623/ The data for China appears to come from studies for the period 1990-94 (see endnote 8v below)
(8t) Breast feeding key to reducing malnutrition in Latin America alertnet (a Thompson/Reuters Foundation Service)// Anastasia Moloney Thu, 15 Oct 2009 14:10 GMT
(8t1) found at https://apps.who.int/nut/db_bfd.htm
(8u) A 24-year Study of Well-Nourished and Malnourished Children Living in a Poor Mexican Village Adolfo Chávez, et al.
(8v) Incidence of childhood type 1 diabetes worldwide. Diabetes Mondiale (DiaMond) Project Group.
Karvonen M, et al., Department of Epidemiology and Health Promotion, National Public Health Institute, Helsinki, Finland Diabetes Care. 2000 Oct;23(10):1516-26.
(8v1) If available: UNICEF Childinfo Statistics by Area/ Child Nutrition, at http://www.childinfo.org/breastfeeding_iycf.php . If that web page is not available, similar data can be found from The World Bank/ Data: Exclusive breastfeeding (% of children under 6 months), UNICEF, State of the World's Children, Childinfo, and Demographic and Health Surveys, at https://data.worldbank.org/indicator/SH.STA.BFED.ZS
(8v2) Diabetes in the Young: a Global Perspective: Global trends in childhood type 1 diabetes Gyula Soltesz, et al., in International Diabetes Federation web page at http://www.idf.org/sites/default/files/Diabetes_in_the_Young.pdf
(8v3) International Diabetes Federation: South and Central America www.idf.org/regions/south-central-america
(8w) http://www.unsystem.org/scn/archives/rwns04/ch28.htm Section 3.5 Breastfeeding and Complementary Feeding Patterns and Trends (citing data sources from the 1990's) 4th Report on the World Nutrition Situation – Nutrition Throughout the Life Cycle January 2000 United Nations Administrative Committee on Coordination Sub-Committee on Nutrition (ACC/SCN)
(8wa) "Nutrition > Exclusive breastfeeding > % of children under 6 months (2002) by country", UNICEF, State of the World's Children, Childinfo, and Demographic and Health Surveys by Macro International.. Retrieved from
http://www.NationMaster.com/graph/hea_nut_exc_bre_of_chi_und_6_mon-breastfeeding-children-under-6-months&date=2002 Data for years other than 2002 would be available in other pages of the same site, selecting the appropriate year for viewing. Data for Mexico for 1999 from González-Cossío T et al. Breastfeeding practices in Mexico: Results from the Second National Nutrition Survey 1999. Salud Pública de México, 2003, 45:S447S489, found in UNICEF Childinfo Statistics by Area/ Child Nutrition (last update Jan. 2012) at http://www.childinfo.org/breastfeeding_iycf.php
(8w1) Evaluation of the Impact of the Baby-Friendly Hospital Initiative on Rates of Breastfeeding Maria Luiza G. Braun, et al. Am J Public Health. 2003 August; 93(8): 1277–1279. PMCID: PMC1447954
(8w2) Trends in diabetes mellitus in Brazil: the role of the nutritional transition Sartorelli DS, Franco LJ., Departamento de Medicina Social, Faculdade de Medicina de Ribeir o Preto, Universidade de São Paulo, Brasil. Cad Saude Publica. 2003;19 Suppl 1:S29-36. Epub 2003 Jul 21.
(8x) V Mijac et al., Role of environmental factors in the development of insulin-dependent diabetes mellitus (IDDM) in Venezuelan children (in Spanish but good abstract in English), Invest Clin. 1995 June;36(2): 73-82 at http://www.ncbi.nim.nih.gv/pubmed/7548302
(8y) HLA-DR-DQ haplotypes and type 1 diabetes in Macedonia. Ilonen J, et al., Immunogenetics Laboratory, University of Turku, Turku, Finland. Hum Immunol. 2009 Jun;70(6):461-3. doi: 10.1016/j.humimm.2009.03.014. Epub 2009 Mar 27
(8z) Republic of Macedonia - Multiple Indicator Cluster Survey 2005-2006. Final Report, Skopje, State Statistical Office of the Republic of Macedonia.
(8z2) Breastfeeding in China: a review Fenglian Xu1 et al., Medical College of Shihezi University; Xinjiang International Breastfeeding Journal 2009, 4:6 doi:10.1186/1746-4358-4-6. Most data drawn from "Results" section. Found at http://www.internationalbreastfeedingjournal.com/content/4/1/6
(8z3) A cohort study of infant feeding practices in city, suburban and rural areas in Zhejiang Province, PR China
Liqian Qiu1, et al., Women's Hospital, School of Medicine, Zhejiang University, PR China International Breastfeeding Journal 2008, 3:4 doi:10.1186/1746-4358-3-4 online at: http://www.internationalbreastfeedingjournal.com/content/3/1/4
(8z4) Prevalence of type 1 diabetes mellitus in 6–18-yr-old school children living in Istanbul, Turkey. Akesen, E.et al., (2011), Pediatric Diabetes, 12: 567–571. doi: 10.1111/j.1399-5448.2010.00744.x
(8z5) found at http://www.childinfo.org/breastfeeding_progress.html See also Istanbul notes: A snapshot of Turkey’s health system In Society on July 10, 2010 at 12:01 am
(8z6) Number Of Diabetics Rises In Republic Of Armenia Yerevan Report, Nov 15th, 2011 at http://www.yerevanreport.com/96191/number-diabetics-rises-republic-armenia/
(9) http://www.fda.gov/biologicsbloodvaccines/resourcesforyou/consumers/ucm167471.htm Also Clin Exp Allergy. 2006 April; 36(4): 402–425. Blackwell Publishing Ltd "Too clean, or not too clean: the Hygiene Hypothesis and home hygiene," SF Bloomfield et al. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1448690/ Also Cell Research advance online publication 24 April 2012; doi: 10.1038/cr.2012.65 "Early exposure to germs and the Hygiene Hypothesis" Dale T Umetsu Division of Immunology, Karp Laboratories, Children's Hospital Boston, Harvard Medical School, Boston, MA http://www.nature.com/cr/journal/vaop/ncurrent/full/cr201265a.html
(10) "Environmental toxicants and the developing immune system: a missing link in the global battle against infectious disease?" Bethany Winans, et al., Reprod Toxicol. 2011 April; 31(3): 327–336. Published online 2010 September 22. doi: 10.1016/j.reprotox.2010.09.004 PMCID: PMC3033466 NIHMSID: NIHMS245165 accessed at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3033466/ citing the following:
Heilmann C, Grandjean P, Weihe P, Nielsen F, Budtz-Jorgensen E. "Reduced antibody responses to vaccinations in children exposed to polychlorinated biphenyls." PLoS Med. 2006;3:e311. [PMC free article
Weisglas-Kuperus N, Patandin S, Berbers GA, Sas TC, Mulder PG, Sauer PJ, et al. "Immunologic effects of background exposure to polychlorinated biphenyls and dioxins in Dutch preschool children." Environmental health perspectives. 2000;108:1203. [PMC free article]
Glynn A, Thuvander A, Aune M, Johannisson A, Darnerud P, Ronquist G, et al. "Immune cell counts and risks of respiratory infections among infants exposed pre- and postnatally to organochlorine compounds: a prospective study". Environmental Health. 2008;7:62. [PMC free article]
Dallaire F, Dewailly E, Muckle G, Vezina C, Jacobson SW, Jacobson JL, et al. "Acute infections and environmental exposure to organochlorines in Inuit infants from Nunavik." Environ Health Perspect. 2004;112:1359–63. [PMC free article]
Dewailly E, Ayotte P, Bruneau S, Gingras S, Belles-Isles M, Roy R. "Susceptibility to infections and immune status in Inuit infants exposed to organochlorines.” Environ Health Perspect. 2000;108:205–11. [PMC free article]
Jedrychowski W, Galas A, Pac A, Flak E, Camman D, Rauh V, et al. "Prenatal ambient air exposure to polycyclic aromatic hydrocarbons and the occurrence of respiratory symptoms over the first year of life." European journal of epidemiology. 2005;20:775–82.
Weisglas-Kuperus N, Vreugdenhil HJ, Mulder PG. "Immunological effects of environmental exposure to polychlorinated biphenyls and dioxins in Dutch school children." Toxicol Lett. 2004;149:281–5.
Guo YL, Lambert GH, Hsu CC, Hsu MM. Yucheng: "Health effects of prenatal exposure to polychlorinated biphenyls and dibenzofurans." Int Arch Occup Environ Health. 2004;77:153–8.
Vos JG, Moore JA. "Suppression of cellular immunity in rats and mice by maternal treatment with 2,3,7,8-tetrachlorodibenzo-p-dioxin." International archives of allergy and applied immunology.
11) Danish Health and Medicines Authority, 2013, Health risks of PCB in the indoor climate in Denmark, at http://sundhedsstyrelsen.dk/publ/Publ2013/12dec/HAofPCBindoorDK_en.pdf
(12) U.S. EPA: The Effects of Great Lakes Contaminants on Human Health at http://www.epa.gov/greatlakes/health/report.htm
Screening for Type 2 Diabetes, Report of a World Health Organization and International Diabetes Federation meeting World Health Organization, Department of Noncommunicable Disease Management 2003 at http://www.who.int/diabetes/publications/en/screening_mnc03.pdf
Type 2 Diabetes in Children and Adolescents, American Diabetes Association at http://www.utpa.edu/bho/PDF_Documents/ADA%20Type 2 diabetes in children.pdf
Epidemiology of Type 1 Diabetes Mellitus at http://books.google.com/books?id=64Z8LjJ3deIC&pg=PA228&lpg=PA228&dq=latency+period+for+diabetes&source=bl&ots=wQk_EU6kAI&sig=4g-itdVKMucovtmaLWjpemTrUI8&hl=en&sa=X&ei=pdnxUIS7Asvy2gWc04GIBg&ved=0CFAQ6AEwBTgK#v=onepage&q=latency period for diabetes&f=false
At http://www.jdf.org/index.cfm?page_id=101982: (Juvenile Diabetes Research Foundation)