Background
Overweight and obesity rates in Australian children is high and is associated with increasing healthcare costs. Importantly the prevalence overweight and obesity varies across socioeconomic and ethnic groups. Recent estimates in 2018–19 suggest that nearly one-third of Australia’s population were born overseas; and 2.4% of the total Australian population comprised of Indian immigrants making them the third largest immigrant population [
1,
2]. Immigrant children from low- and middle-income countries (a classification that includes India) have a higher risk of overweight/obesity than children of Australian-born mothers or children of mothers from high-income countries [
3]. Zulfikar et.al, reported that children born to mothers from low- to middle-income countries were 50–70% more likely to be overweight or obese [
3], increasing the risk of developing type 2 diabetes, elevated triglycerides, blood pressure, and cardiovascular disease in adulthood [
4]. The prevalence of overweight and obesity in Australian children and adolescents between the ages of 2–17 years is high (25%) [
5], resulting in healthcare costs of approximately AUD 43 million in 2015 [
6].
One key modifiable risk factor for developing childhood overweight or obesity is dietary intake [
7]. The World Health Organization (WHO) has stressed the importance of the first 1000 days of life (from conception to the first two years after birth) as a critical window for nutritional intervention to reduce the risk of overweight or obesity [
8]. A recent review of childhood obesity prevention interventions highlighted the programming effect of early nutrition, including infant feeding practices in obesity development [
9].
To support optimal infant nutrition, the WHO, Australian Dietary Guidelines and Indian Infant and Young Child Feeding Guidelines (IYCF) recommend exclusive breastfeeding for the first six months followed by the introduction of solids at around six months of age [
10‐
12]. The evidence-based guidelines highlight the short-term and long-term benefits of breastfeeding for infants, such as slower weight gain in childhood and adolescence and lower obesity risk in adulthood [
13]. Early introduction of solids (before the age of four months) and infant formula may contribute to excessive consumption of calories and protein that may be a risk factor for the development of overweight and obesity [
14,
15].
Given the higher risk of overweight/obesity in Indian immigrant children, and the potential association of early feeding to child adiposity, it is crucial to understand infant feeding practices in Indian immigrant mothers to promote best-practice [
3]. International studies have shown that infant feeding practices among ethnic mothers (including those with an Indian background) are influenced heavily by culture, socioeconomic status, family beliefs, support from family and friends, maternal age and acculturation and the influence of grandparents [
16‐
19].
Ethnic differences in infant feeding practices such as breastfeeding, pre-lacteal feeding, formula feeding, exposure to other liquids (cow’s milk, fruit juice, cordials, teas) and exposure to solids have been documented previously [
20‐
22]. Different cultural beliefs are likely drive these ethnic differences in infant feeding. For instance, studies have shown that colostrum is perceived as harmful and pre-lacteal feeds right after birth (honey, jaggery, cow’s milk) are perceived beneficial in Indian culture, which doesn't align with infant feeding guidelines [
21‐
23]. Few studies examine first foods offered to infants by ethnicity. However, emerging studies have shown that ethnic mothers (including Indian-born) are more likely to introduce sweet foods, cereals, fruits, juice, vegetables and some cases, rice and lentil-based foods as the first foods instead of single cereal foods as recommended by the infant feeding guidelines [
12,
22,
24].
The current literature examining infant feeding practices of Indian-born mothers in Australia is minimal [
21]. Given the potential for higher prevalence of obesity in the Indian-immigrant population; an improved understanding of infant feeding practices of this specific ethnic group in Australia is warranted. Knowledge regarding infant feeding practices will allow health professionals, and policymakers to design and endorse tailored intervention programs for the Indian community living in Australia that aim to to promote optimal infant feeding behaviours.
Therefore, this study aimed to compare infant feeding practices such as breastfeeding, infant formula feeding, timing of introduction of complementary feeding (feeding other liquids and solids) of Indian-born versus Australian-born mothers living in Australia.
Discussion
The present study is the first known study to compare infant feeding practices in a large and nationally representative sample of Indian-born mothers and Australian-born mothers living in Australia. These two groups showed significant differences in infant feeding practices.
Overall, Indian-born mothers were more likely than were Australian-born mothers to meet Australian infant feeding guidelines relating to prolonged duration of breastfeeding, higher likelihood of currently breastfeeding, later exposure to water and solids and reduced likelihood of introducing solids before six months. However, infant feeding practices such as exposure to water-based drinks, fruit juice, cow’s milk and formula were found to be suboptimal and fell short of infant feeding guidelines.
Breastfeeding
Higher breastfeeding rates amongst the Indian-born mothers’ contrasts with other Australian studies where migrant Chinese and Vietnamese mothers living in Australia showed a low breastfeeding rate when the infant was three months of age (36% and 60%) [
29,
30]. However, findings from the current study align with those from national and international studies (Australia, UK and the US), where Indian-born immigrant mothers showed higher breastfeeding rates and breastfeeding duration compared to white mothers [
16,
22,
31,
32].
The higher breastfeeding rate among Indian mothers may be due to stronger views about breastfeeding as an integral aspect of their cultural heritage and positive influence of social support on breastfeeding practices for Indian immigrant mothers, as shown in a Melbourne study [
16,
21,
24,
31,
32]. Consistent with our findings, results from Australian and UK studies have shown that ethnicity predicted the likelihood of an infant currently receiving breastmilk and prolonged breastfeeding compared to white mothers [
33,
34]. Similarly, an Australian study that found that Indian-born mothers breastfed their infants for eight weeks longer than Australian-born mothers, thus suggesting that ethnicity is a predictor of breastfeeding practices [
35]. In the present study, despite the positive finding, more than half of Indian-born mothers had stopped breastfeeding before six months, suggesting a high proportion not breastfeeding their infants for the first 12 months.
Given the protective effect of breastfeeding through the first 12 months on infant weight status and dose-dependent relationship with obesity, the earlier cessation of breastfeeding observed amongst both the groups, it is likely that infants in both groups are at increased risk of being overweight and obese [
36,
37].
Limited evidence exists on formula feeding practices amongst infants of Indian-born mothers in Australia, and the international evidence is mixed. Although there were no in-between differences groups for formula feeding, a very high proportion (79– 81%) of infants in both the groups consumed formula at two months of age. Formula feeding alone or combined has been associated with higher overweight or obesity risk [
38]. These results suggest that the current formula feeding practices of infants of Indian-born and Australian-born mothers may put these infants at higher risk of subsequent overweight or obesity.
The Australian infant feeding guidelines do not recommend cow’s milk, fruit juice or any water-based drinks (tea, coffee, soft drinks, cordials or any other beverages) for infants under 12 months of age [
12]. In the present study, a large number of mothers, regardless of ethnicity, did not meet these guidelines. Furthermore, compared to infants of Australian-born mothers, Indian-born mothers in this study introduced fruit juice significantly earlier. These findings are consistent with previous literature where ethnic mothers (Pakistani, Asian immigrant mothers (UK) and Chinese immigrant mothers in Australia) have a higher likelihood of introducing fruit juice sooner than white mothers [
39‐
41]. Moreover, evidence has shown that Hispanic, black and black non-Hispanic infants consumed a significantly higher proportion of sugar-sweetened beverages (SSBs) between 1 – 12 months than white infants [
42]. Given the link between SSB consumption and obesity, it is possible that infants of Indian-born mothers are at increased risk of developing obesity and insulin resistance in adulthood [
43‐
46]. A UK cross-sectional study by Ehtisham et al., revealed that compared to white European adolescents, South Asian adolescents (including Indian) were significantly overweight/ obese (12% vs 42%), had significantly higher fasting insulin levels, were less insulin sensitive and had significantly higher total cholesterol levels [
46]. The increased risk of diabetes amongst South Asian adolescents may be contributed to acculturation. In a Canadian study, Adjel et al. reported that long-term immigrants (arrived/migrated > 10 years) had significantly greater odds of getting diabetes (OR:2.30,
p < 0.001) compared to newly arrived immigrants (arrived/migrated < 10 years; OR:1.43,
p = 0.234) or white Canadian-born adults suggesting a link between acculturation and increased likelihood of suffering from diabetes [
47].
Additionally, the current study also showed that one-fifth of infants of Indian-born mothers were introduced to cow's milk by around nine months, which was significantly earlier compared to infants of Australian-born mothers. Early exposure to cow's milk (before 12 months) has been associated with an increased risk of gastrointestinal blood loss, leading to iron deficiency anaemia and an increased risk of developing chronic diseases such as diabetes and renal overload [
48]. Early education regarding the harmful effects of early exposure to cows' milk is warranted in Indian-born mothers to prevent associated health risks.
Introduction to solids
Around 57% of Indian-born mothers and 88% of Australian-born mothers introduced soft, semisolids and solids before six months of age, which doesn't align with Australian infant feeding guidelines [
12]. However, Indian-born mothers were less likely to introduce solids before six months compared to Australian-born mothers. This ethnic difference in the solid introduction has been previously reported in some Australian studies where Chinese, Vietnamese and Indian mothers showed a reduced likelihood of introducing solids before four months [
39,
49]. Current findings are consistent with previous national and international literature where lower acculturation and positive breastfeeding attitudes amongst Indian-immigrant mothers resulted in the delayed introduction of solids [
16,
49]. It is, therefore, possible that Indian-born mothers in this study were less acculturated and had positive attitudes towards breastfeeding, leading to a delayed introduction to solids.
There is limited evidence on the type of foods infants are offered during weaning amongst Indian-born mothers. As shown in international studies, a higher proportion of immigrant mothers from India, Pakistan and Turkey offer sweet foods as introductory foods during weaning, accompanied by a ceremony [
40,
50,
51]. Infants from immigrant mothers were also more likely to consume commercial baby foods, chips or roast potatoes, sugar-sweetened drinks and fruit juice compared to white infants [
41]. Given this evidence, understanding how infants are fed helps us to understand how to support parents to provide healthy food intakes to promote healthy growth in infants [
52]. Future studies examining weaning foods infants are exposed to in Indian immigrant families is warranted.
Strengths and limitations
The current study contributes to crucial knowledge regarding differences in infant feeding practices of Indian-born mothers compared to their non-immigrant counterparts living in Australia, forming a baseline for future research. A particular strength of this study is that it draws on a large randomly selected sample of nationally representative data on infant feeding practices, thus reducing selection bias and increasing generalisability of the findings to the broader population of Indian-immigrant mothers living in Australia. The study also adjusted for a range of covariates that are linked with infant feeding practices. However, there are study limitations to acknowledge. The Australian National Infant Feeding Survey was conducted ten years ago, but remains the most recent and comprehensive national infant feeding survey in Australia. Given the cross-sectional nature of the data, causality cannot be inferred. Other limitations include the potential of recall bias and social desirability bias, and risks inherent to self-reported questionnaires. Further, the current study did not assess infant anthropometry nor length of acculturation. It will be valuable to include these measures in future studies.
Future recommendations
Future studies amongst Indian-born mothers are warranted to explore the implications of ethnicity on infant feeding practices such as breastfeeding initiation, pre-lacteal feeding, combination feeding of breastmilk and formula and types of solids introduced. Furthermore, the influence of cultural beliefs, confinement practices, biomedical factors such as mode of delivery, family support from parents, grandparents, friends and health care professionals and acculturation on infant feeding practices amongst this group is warranted. Due to the increased risk of overweight and obesity the Indian-immigrants [
3], there is also a need to examine the association between infant feeding practices and child anthropometry; along with the long-term incidence of overweight and obesity in children; and how this compares to children of Australian-born mothers.
Conclusion
The current study has provided valuable insight into infant feeding practices amongst Indian-born mothers living in Australia. Health-promoting practices of Indian-born mothers included prolonged duration of breastfeeding, later introduction of solids, water and reduced likelihood of introducing solids before six months. However, sub-optimal and potentially obesogenic infant feeding practices such as the early introduction of water-based drinks, fruit juice, cow's milk and formula were evident amongst Indian-born mothers. Given the increase in migration from India alongside the rise in the prevalence of childhood overweight/obesity, it is crucial to set up the children of Indian immigrants for optimal growth and health behaviours for life. These findings help build a picture where to focus resources to support Indian-born mothers to feel confident to desist formula and other sweetened fluids in their infant's early life.
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