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4


Overweight and obesity epidemic in the United States: The obesity epidemic in the United
States (US) is a well-established public health crisis associated with immense national healthcare
expenditures [1-4]. Obesity rates among American adults and children have been increasing over
the past three decades with a slight leveling off in recent years [1,9]. Over 35% of US adults and
almost 17% of US children and adolescents are classified as obese [9]. An effort to prevent and
reduce childhood obesity prevalence is of particular interest, because overweight or obese
children are more likely to be overweight or obese later in life, leading to chronic and possibly
fatal diseases such as type 2 diabetes and cardiovascular disease [5-8]. The first four months of
life has been identified as a potentially critical intervention period for prevention of both rapid
weight gain in the first year of life and subsequent overweight and obesity in childhood [9]. For
this time period, breastfeeding is recognized as the healthiest mode of infant-feeding, and may be
protective of rapid weight gain early in life [10, 11].

Self-regulation and normal infant intake for breastfed and formula-fed infants: Dewey and
colleagues [12] conducted a landmark study comparing weight-for-length and percent fat mass
between exclusively breastfed infants and exclusively formula-fed infants. There were 46
breastfed infants and 41 formula-fed infants included in the study, and the researchers controlled
for potential confounding variables such as parental socioeconomic status, ethnicity, maternal
education and anthropometric measurements, and infant sex and birth weight. Results indicated
that breastfed infants had a significantly lower weight-for-length compared to formula-fed
infants between 7 and 24 months, and the greatest difference occurred between 11 and 16
months. Also, the formula-fed infants reached a greater peak in percent body fat compared to



3
breastfed infants during the first year of life. Dewey and colleagues concluded that the probable
main contributing factor for these results was the difference in total energy intake between
groups. Formula-fed infants on average consumed significantly more kcal/day during the first
year of life compared to the breastfed infants, with intake ranging from 79-156 kcal more per day
for formula-fed infants [12].
Li and colleagues [13] further explored infant self-regulation to determine if breastfed
infants consumed fewer kcal per day due to the ability to better self-regulate intake, as they are
thought to be more in control of when a feed is terminated, and there is no external influence on
energy-density [14]. Breastfed infants must actively suckle to feed whereas formula-fed infants
can be more passive, and caregivers might manipulate the ability of formula-fed infants to self-
regulate. Therefore, it was hypothesized that infants who were fed expressed breastmilk from a
bottle would grow comparably to the formula-fed infants, despite differences in infant-feeding
mode. Li and colleagues [13] tested infant weight status in the first year of life as an outcome of
milk type (human vs. nonhuman milk) and feeding mode (breast vs. bottle). They found that
bottle-feeding was associated with greater infant weight status at one year of age, regardless of
the type of milk offered. In a separate study, Li and colleagues [15] found that infant weight
status at one year was positively associated with infant-initiated bottle emptying. This suggests
that breastfed infants may receive subtle signals over the course of a breastfeeding episode,
possibly in the form of increasing fat concentrations toward the end of a feed [13]. Theoretically,
secondary to emulsification of bottles of pumped breastmilk, regardless of milk type, bottle-fed
infants may not experience this variation in macronutrient profile, potentially affecting internal
hunger and satiety cues.




6
Need for intervention targeting formula-fed infants: Despite initiatives to increase worldwide
breastfeeding initiation and duration rates, many infants, particularly in the US, are being offered
infant formula and some are never breastfed. According to the Centers for Disease Control and
Prevention (CDC) 2011 Breastfeeding Report Card, about 25.4% of US infants and about 34.4%
of Tennessee infants are never breastfed [16]. The rates of exclusive breastfeeding continue to
decrease as infants age, with only 35.0% of US infants being exclusively breastfed at 3 months
of age and a mere 14.8% of US infants being exclusively breastfed at 6 months of age [16]. For
Tennessee infants, these rates at 3 months and 6 months are 27.9% and 12.8%, respectively [16].
Thus, breastfeeding initiation and duration rates in Tennessee are below the national averages.
Furthermore, Grummer-Strawn and colleagues showed that infants who were not being
exclusively breastfed were offered other milks, including cows milk and milk substitutes [17].
On average, the use of cows milk was not seen until the infants were about 9-10 months of age
[17]. Therefore, the younger infants who were not exclusively breastfed were primarily offered
infant formula. There are many risks associated with incorrect preparation of infant formula,
whether the caregiver is over-concentrating, diluting, or modifying the formula with the addition
of infant cereal and/or solid foods [18-24].

Modifying infant formula, overfeeding, and associated consequences: Behaviors such as
adding cereal to bottles, early introduction of solid foods, and overfeeding, contradict infant-
feeding recommendations for infants less than 4 months of age [18, 25]. Both addition of cereal
and early introduction of solid foods are thought to induce sleep, causing the infant to sleep for
longer periods of time, possibly motivated by maternal convenience [26-28]. Also, there is some
evidence supporting a moderate decrease in reflux or spit-up when cereal is added to the infant



7
formula [29]. However, adding cereal to an infants bottle could increase the risk for dental
caries, allergies, and bacterial infections [18, 21-24, 30-32], and early introduction of solid foods
could lead to overweight/obesity in childhood [33, 34].
Overfeeding is another concerning infant-feeding behavior. There are a variety of
practices leading to overfeeding and excess infant caloric intake other than adding cereal to the
bottle or early introduction of solid foods. For example, intentional and unintentional over-
concentration or offering more than 20 kcal per ounce of formula could be one mechanism
resulting in a heavier infant [35]. Premature infants are offered formula that is 24 kcal per ounce
to stimulate catch up growth [35]. Therefore, theoretically, even a small manipulation in
formula concentration may lead to unintentional weight gain over time for healthy infants.
Conversely, dilution of infant formula (<20 kcal per ounce) can lead to the infant being hungry
more often and communicating more frequent hunger cues, another risk for subsequent
overfeeding. In addition, overfeeding may occur simply by offering too many ounces per feed.
Although little research has been conducted regarding incorrect preparation of infant formula and
later overweight/obesity, the association is theoretically plausible due to the potential for excess
caloric intake per ounce (over-concentration), more frequent hunger cues (dilution), or more total
ounces offered.

The WIC-eligible population and infant feeding practices: The Special Supplemental
Nutrition Program for Women, Infants and Children (WIC) serves nearly half of the infants born
in the US and the WIC-eligible (income > 185% Federal Poverty Level) population is more
likely to be overweight or obese later in life [36, 37]. Not only are low-income mothers more
likely to formula feed, but they are also at a greater risk for adding cereal to the bottle and early



8
introduction of solid foods [27, 28, 38, 39]. Crocetti and colleagues [27] found that out of 102
female primary caregivers, 76% were WIC participants, 39% of their infants were never
breastfed, and 44% introduced solid foods, including infant cereal, prematurely. Infants who
were given infant cereal before four months of age were also 31 times more likely to receive
other solid foods before four months of age. Of the mothers who offered solid foods prior to four
months of age, 80% claimed that their infants were not satisfied by formula or breastmilk alone,
and 53% stated that solid foods induced better sleep for their infants. Heinig and colleagues [28]
also discovered from focus groups with WIC participants, that many mothers reported the use of
fluids and solid foods to influence infant behavior and to induce infant sleep.
In addition, this population of low-income mothers has been shown to have increased
likelihood of inaccurate infant formula preparation practices that may increase the risk for later
overweight/obesity [37]. WIC provides infant formula for formula-feeding mothers but not
enough to sustain infants for the entire month [40]. Since WIC is a supplemental nutrition
program, the mother is responsible for purchasing formula with her own means after her supply
each month is depleted. Formula is much more expensive when compared to both infant cereal
and solid foods, so supplementing formula feeds with these alternatives may seem to be the most
logical and affordable option for low-income mothers. More convenient and cost-effective
behaviors can be tempting, especially if mothers are unaware of the potential long-term
consequences of incorrect infant formula preparation practices.

Online nutrition education in low-income populations: The US Department of Health and
Human Services, Education, and Commerce agrees that internet access in the home is a priority
for US citizens for health promotion and education purposes [41]. Reaching individuals by



9
means of the internet is a more cost-effective tool to promote nutrition education messages
compared to delivery in a traditional classroom setting [42, 43]. This approach allows for greater
dissemination of messages to a broader audience, including those living in rural areas, who might
be otherwise isolated from nutrition education due to lack of transportation and general lack of
resources [42-44]. Research indicates that about two-thirds of low-income individuals living in
rural areas have internet access [41, 42]. WIC, among other government health organizations, are
currently implementing online learning as an alternative to the traditional classroom learning
approach [43]. Even if online learning modules are not proven to be practical as a stand-alone
teaching strategy, online modules could be used in conjunction with a traditional classroom
approach [42]. This computer-based teaching strategy must be proven effective with regards to
initiating positive health behavior changes. Limited research is currently available testing the
effectiveness of online nutrition interventions among low-income mothers using randomized-
controlled study designs [41].

Implications for Future Research: There is a need to address the incorrect formula preparation
practices among low-income, formula-feeding mothers, including over-concentration, dilution,
and modifications/additions to infant formula. Initiating formula preparation behavior changes
among mothers may lead to positive short-term and long-term health outcomes for infants as
well as a decrease in associated national healthcare expenditures. An early intervention teaching
mothers how to correctly prepare formula bottles in a cost-effective, convenient manner must be
tested for validity before being distributed for use in various government health organizations,
such as WIC.




10
Conclusion: There is an unmet opportunity to address inappropriate formula preparation
practices among US mothers such as over-concentration, dilution, and modifications or additions
to infant formula. More research is needed in the field of online nutrition education, especially
among the low-income population. Future research should address this gap by testing behavior
changes among low-income, formula-feeding mothers as a result of an online nutrition education
intervention.

5%/%"%1&%*


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DAkLING study. Dav|s Area kesearch on Lactat|on, Infant Nutr|t|on and Growth. 1*./ 3/-(%/.+
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14. Podges LA, !ohnson SL, Pughes SC, Popklnson !M, 8uLLe nl, llsher !C: Deve|opment of the
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11
13. Ll 8, leln S8, Crummer-SLrawn LM: Assoc|at|on of breastfeed|ng |ntens|ty and bott|e-empty|ng
behav|ors at ear|y |nfancy w|th |nfants' r|sk for excess we|ght at |ate |nfancy. 3-(%/.+%*6 2008,
122 Supp| 2:S77-84.
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27:490-493.
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f|rst year of ||fe. 3-(%/.+%*6 2008, 122 Supp| 2:S36-42.
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68:430-440.
20. Mollna kM, klely M: Understand|ng depress|ve symptoms among h|gh-r|sk, pregnant, Afr|can-
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|n|t|a| cerea| exposure |n |nfancy and r|sk of |s|et auto|mmun|ty. !1,1 2003, 290:1713-1720.
22. CarleLLl C, CaLLaneo A: nome preparat|on of powdered |nfant formu|a: |s |t safe? 1*./ 3/-(%/.+
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24. oole !A, 8arrlga k, Leung u?, Poffman M, LlsenbarLh CS, 8ewers M, norrls !M: 1|m|ng of |n|t|a|
exposure to cerea| gra|ns and the r|sk of wheat a||ergy. 3-(%/.+%*6 2006, 117:2173-2182.
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30. WIC: Irequent|y asked quest|ons about cerea|. Maryland ueparLmenL of PealLh.
31. Zlegler A-C SS, Puber u, Pummel M, 8onlfaclo L: Lar|y |nfant feed|ng and r|sk of deve|op|ng
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12
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40. Case CM, Plno !: Cn||ne Nutr|t|on Lducat|on: Lnhanc|ng Cpportun|t|es for L|m|ted-kesource
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41. 1eng C-C 88, Amy 8, Coplen 1, nlepraschk C, Chene-Cpare A, SmlLh M: An Interact|ve Cn||ne
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94.+ '(4* <-8/5 2010, 42:410-416.






13
!"#$%&' 8499+":


Preparing infant formula incorrectly lead to many short-term and long-term negative health
outcomes for infants [18, 21-24, 30-32]. Potential consequences include a greater risk for
bacterial infections, dental caries, allergies, and additional calories for the infant that may be
associated with unfavorable weight gain [18, 21-24, 30-32]. Rapid weight gain during the first 4
months of life is predictive of overweight and obesity later in life [5, 6, 9, 45]. Overweight and
obese children and adults have an increased risk of several associated co-morbidities, such as
type 2 diabetes and cardiovascular disease, and the obesity epidemic is a well-established public
health crisis in the United States (US) [5-8]. Preventing rapid weight gain in infants has been
identified as a potential intervention point for obesity prevention, particularly for formula-fed
infants [9, 13].


There is an unmet opportunity to address improper formula preparation practices among US
mothers such as over-concentration, dilution, and modifications or additions to infant formula.
The United States Department of Agriculture (USDA) has developed a series of core
nutrition education messages for mothers of children ages two and older [46]. These
messages were designed to promote healthy eating practices among mothers and their
children; however, the messages do not speak to the unique nutrition needs of infants. In
order to address this gap, the research team has established points of intervention based on the
qualitative data analysis of one-on-one, audio-recorded, in-depth interviews with low-income,
formula-feeding mothers. The research team developed two nutrition education messages, using
the nominal group process, that were designed to help mothers prepare infant formula correctly
[47]. These messages emphasize the importance of preventing the overfeeding of infants and the
potentially harmful effects of additions, such as cereal or the premature introduction of solid
foods. An online intervention will be developed based on these nutrition education messages and
tested using a randomized-controlled study design. The research team will determine if the
intervention results in formula preparation behavior change among mothers. The purpose of this
study is increase availability of a novel nutrition education intervention to effectively improve
formula preparation practices among low-income, formula-feeding mothers, thus potentially
improving short-term and long-term health outcomes for US infants.


Low-income, formula-feeding mothers with infants < 3 months of age will be recruited to
complete online modules designed to test the nutrition education messages. Infant intake will be
recorded by mothers for 24 hours (baseline), after which the mothers will be randomly
assigned to one of three groups: intervention online module 1 (educational video), intervention
online module 2 (educational video plus interactive segments), or online control module
(educational sham video). Within two weeks of module completion, infant intake will be
recorded by mothers a second time for 24 hours (follow-up). Intake data will be analyzed for
significant differences in behavior (ex: amount of infant formula offered and/or amount of infant
formula consumed).
!"#$%&' ;%*&"3)'3#1

<1'"#=4&'3#1 +1= !"#.,%9 8'+'%9%1'

The obesity epidemic in the United States is a well-established public health crisis associated
with immense national health care expenditures [1-4]. The first four months of life has been
identified as a potentially critical intervention period for prevention of both rapid weight gain in
the first year of life and subsequent overweight and obesity in childhood [9]. Since overweight
and obese children are more likely to be overweight or obese as adults, preventing rapid weight
gain in the first four months of life could help decrease national obesity rates and associated co-
morbidities such as type 2 diabetes and cardiovascular disease [5-8]. For this time period,
breastfeeding is recognized as the healthiest mode of infant feeding, and may be protective of
rapid weight gain early in life [10].

The World Health Organization (WHO) recommends exclusively breastfeeding infants for the
first 6 months of life and continuing breastfeeding up to 2 years of age [10, 11]. Despite
initiatives to increase worldwide breastfeeding initiation and duration rates, many infants,
particularly in the US, are being offered infant formula, and some are never breastfed [17, 48].
According to the Centers for Disease Control and Preventions 2011 Breastfeeding Report Card,
about 25.4% of US infants, and about 34.4% of Tennessee infants, are never breastfed [16]. The
rates of exclusive breastfeeding continue to decrease as infants age, with only 35.0% of US
infants being exclusively breastfed at 3 months of age and a mere 14.8% of US infants being
exclusively breastfed at 6 months of age [16]. For Tennessee infants, these rates at 3 months and
6 months are 27.9% and 12.8%, respectively [16]. Thus, breastfeeding initiation and duration



13
rates in Tennessee are below national averages. Infants less than four months of age who are not
breastfed are most likely offered infant formula instead [17]. There are risks associated with
incorrect preparation of infant formula, whether the caregiver is over-concentrating, diluting, or
modifying the formula with the addition of infant cereal and/or solid foods [18, 21-24, 30-32].

Modifying infant formula, overfeeding, and associated consequences: Behaviors such as
adding cereal to bottles, early introduction of solid foods, and overfeeding, contradict infant-
feeding recommendations for infants less than 4 months of age [18, 25]. Both the addition of
cereal and the early introduction of solid foods are thought to induce and extend infant sleep, and
are behaviors potentially motivated by maternal convenience [26-28]. Mothers also report adding
infant cereal to bottles of infant formula, in an effort to manage reflux or spit-up [28, 29].
Though there is limited evidence indicating a moderate decrease in reflux or spit-up when cereal
is added to the formula [29], this is only to be indicated in specific, diagnosed situations [49] and
is otherwise recommended against for infants less than 4 months of age [18, 25]. In fact, adding
cereal to bottles of infant formula is thought to increase the risk for dental caries, allergies, and
bacterial infections [18, 21-24, 30-32]. In addition, cereal in the bottle could theoretically
contribute to excess calories for the infant and subsequent overfeeding [34].

In addition to cereal in the bottle and early solid food introduction, there are other practices
leading to excess infant intake such as over-concentration, dilution, or too many ounces offered.
For example, intentional and unintentional over-concentration, or offering more than 20 kcal per
ounce, of formula could be one mechanism resulting in a heavier infant [35]. Premature infants,
if also low birth weight, are offered formula that is 24 kcal per ounce to stimulate catch up



16
growth [35]. Therefore, theoretically, even a small manipulation in formula concentration may
lead to unintentional weight gain over time for healthy infants. Conversely, dilution of formula
(<20 kcal per ounce) may lead to the infant being hungry more often and communicating more
frequent hunger cues, another risk for subsequent overfeeding. In addition, overfeeding may
occur simply by offering too many ounces per feed. Although little research has been conducted
regarding incorrect preparation of infant formula and later overweight/obesity, the association is
theoretically plausible due to the potential for excess caloric intake per ounce (over-
concentration), more frequent hunger cues (dilution), or more total ounces offered.

Explanation for targeting the WIC-eligible population: Targeting those eligible for the
Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is appropriate
for this project because WIC serves nearly half of the infants born in the US and because this
low-income population (income > 185% Federal Poverty Level) is more likely to be overweight
and obese later in life [36, 37]. Not only are low-income mothers more likely to formula feed,
but they are also at a greater risk for adding cereal to the bottle and for early introduction of solid
foods [27, 28, 38, 39]. In addition, this population of low-income mothers has been shown to
have increased likelihood of inaccurate infant formula preparation practices that may increase the
risk for later overweight/obesity [37]. WIC provides a standard amount of infant formula per
month [40]. However, as infants grow larger, the standard amount is eventually less than the
infant needs for the entire month [40]. Since WIC is a supplemental nutrition program, parents
are responsible for purchasing formula after this monthly supply is depleted. This is of concern,
as formula is much more expensive than both infant cereal and solid foods, and supplementing
formula feeds with these alternatives may seem to be the most logical and affordable option for



17
low-income populations. More convenient and cost-effective behaviors can be tempting,
especially if mothers are unaware of the potential long-term consequences of improper infant-
feeding practices or if the behaviors are considered incongruent with real world needs [28].

Preliminary data from previous phases of this project: Preliminary data suggest that mothers
eligible for WIC are frequently preparing powdered infant formula in a way that may be
detrimental for their infants short-term and long-term health (pilot work). In addition, during in-
depth interviews, mothers report never being advised by healthcare providers about how to
correctly prepare powdered infant formula. Pilot work in a low-income, formula-feeding
population, conducted in this laboratory, has revealed a population that recalls anxiety and
discomfort associated with learning to prepare a bottle of infant formula. Mothers in this
population report seeking advice from family members and peers, in addition to seeking advice
from health care professionals. This is consistent with findings from previous research conducted
by Heinig and colleagues [28].

Results from earlier phases of this study suggest that infants were being fed significantly more
than the recommended amount, and possibly even more than reports of actual intake in the
literature [12, 50]. During Phase I of this project, the same infants were followed over time and
data were collected at ~2 months and ~4 months of age. Preliminary data from Phase I suggest
that bottle preparation at ~2 months is linked to weight status at ~4 months. During qualitative,
in-depth interviews, occurring in Phase II, mothers reported that offering too many ounces per
feed is related to a variety of outcomes such as spitting up and bellyaches. These data illustrate



18
the importance of intervening with WIC-eligible mothers and the potential implications of
preparing infant formula incorrectly.

Justification of an online intervention: The research team will deliver nutrition education
messages, targeting formula preparation practices, to WIC-eligible mothers through an online
learning module. The US Department of Health and Human Services, Education, and Commerce
agrees that internet access in the home is a priority for US citizens for health promotion and
education purposes [41]. Reaching individuals by means of the internet would be a more cost-
effective tool to promote nutrition education messages, compared to delivery in a traditional
classroom setting [42, 43]. This approach allows for greater dissemination of messages to a
broader audience, including those living in rural areas, who might be otherwise isolated from
nutrition education due to lack of transportation and general lack of resources [42-44]. Second,
recent research indicates that about two-thirds of low-income study participants living in rural
areas have internet access [41, 42]. Not only would an online intervention be more cost-effective
and reach a larger audience, but offering this type of tool would be in alliance with the strategies
government health organizations, such as WIC, are currently implementing [43]. Even if the
online learning module is not shown to be practical as a stand-alone teaching strategy, the
module could be used in conjunction with a traditional classroom approach [42]. Offering access
to the online tool would require minimal additional effort for the staff of government and
community health organizations and would provide another level of education that may enhance
knowledge retention and result in positive health behavior changes.




19
Despite valid justification of utilizing online delivery of nutrition education messages, this
teaching strategy must be proven effective with regards to initiating positive health behavior
changes. Limited research is currently available testing the effectiveness of online nutrition
interventions among low-income mothers using randomized-controlled study designs. The
proposed study will address this gap by not only testing the nutrition education messages, but
also by developing an online teaching strategy, thus enhancing the literature available regarding
online delivery of nutrition education messages and associated behavior changes.

Need for intervention: Although breastfeeding is the recommended mode of infant feeding,
there is a critical need to establish interventions targeting proper formula preparation and infant
feeding behaviors among those who choose to formula feed or are unable to breastfeed their
infants [10, 11, 16]. Efforts to increase national breastfeeding rates should continue so US infants
can be as healthy as possible. In the meantime, the large population of formula-feeding mothers
needs to be offered guidance in order to prepare infant formula in an appropriate manner to
potentially decrease the negative health outcomes associated with incorrect formula preparation.
Initiating formula preparation behavior changes among mothers would lead to positive short-
term and long-term health outcomes for infants as well as a decrease in national healthcare
expenditures. Early intervention is critical to prevent mothers from engaging in inappropriate
formula preparation practices that may be detrimental to their infants short-term and long-term
health. Given the public health importance, there is a need for a standard education module to
illustrate to formula-feeding mothers how to correctly prepare infant formula. An early
intervention, teaching mothers how to properly prepare formula bottles in a cost-effective,
convenient manner must be tested for effectiveness before being distributed for use in various



20
government health organizations such as the Expanded Food and Nutrition Education Program
(EFNEP) and WIC.

Dr. Katie Kavanagh, the principal investigator (PI), and an experienced researcher in the field of
infant-feeding, will be supervising the project and collaborating with two Co-principal
investigators (Co-PIs), Dr. Janie Burney and Dr. Betty Greer with University of Tennessee
Extension. Dr. Burney and Dr. Greer have extensive experience with message transmission and
online module development, so the research team will be highly qualified to implement this
online intervention.

Innovation: To the research teams knowledge, there are no current preventative nutrition
education interventions targeting infant formula preparation, specifically addressing the issues of
over-concentration, dilution, and modification to infant formula.

Government health organizations, such as WIC, are beginning to offer services online and are
implementing computer-based learning strategies on-site [51]. The online learning module
generated from this study will coincide with the increasing use of technology by government
health organizations. The online nutrition education modules developed and tested as an
objective of this project could be offered in addition to traditional classes or as a stand-alone
teaching strategy. More research is needed in the field of online nutrition education, especially
among the low-income population [41]. This study will address this gap by testing behavior
changes among formula-feeding, low-income mothers as a result of an online intervention. The



21
research team will provide an innovative approach that addresses the current and future needs of
government health organizations by utilizing computer-based learning.

>.$%&'36%*
Objective 1: Conduct a randomized-controlled trial, to determine if targeted nutrition
education messages, designed to increase compliance with infant-feeding
recommendations and delivered in an online format (intervention groups 1 and 2), will
result in knowledge and behavior change, compared to messages unrelated to infant
nutrition (control group), and to do so in a population of low-income, formula-feeding
mothers with infants less than 3 months of age.

Objective 2: Determine if messages, delivered using embedded interactive
subcomponents (intervention group 2), result in greater knowledge and behavior change,
compared to a more traditional slideshow format (intervention group 1).
5%*%+"&? @%'?#=*

Brief description of Phase I and Phase II: All phases of this study recruited WIC-eligible,
formula-feeding mothers (>16 years of age) with healthy infants < 3 months old.

Phase I: During Phase I, the research team collected infant formula samples for one 24 hour
period at two different time points (~2 months of age and ~4 months of age). At each time point,
infant weight, length, and head circumference were measured by trained research staff. In
addition, mothers completed infant intake forms for 48 hours (samples collected for the last 24
hours) to assess the amount of formula offered to the infant, amount leftover after feeding,
whether or not cereal was added to the bottle, how much cereal was added (if any), amount of
spit-up (if any), and who fed the infant the bottle. The intake forms also accounted for calories
obtained from other sources, such as juice or solid foods, and how many hours the infant was
sleeping in between feeds. The 54 mothers who participated at both time points also completed a
detailed questionnaire at each time point about infant-feeding behaviors and beliefs.

Phase II: Phase II focused on developing nutrition education messages based on the findings
from Phase I and additional one-on-one, in-depth recorded interviews with mothers about
feeding their infants also conducted during this phase. The script for the interview was designed
by an expert committee, and the research team received extensive training from Dr. Suzie
Goodell, a qualitative research specialist. Prior to the interview, mothers were asked to
demonstrate to the research assistants how they normally prepare formula bottles, and
observations were recorded. A total of 13 interviews were completed, and all members of the



23
research team, including Dr. Goodell, agreed that saturation was reached after the first 10
interviews.

Nutrition education messages were developed by the research team based on prevalent improper
formula preparation practices encountered during Phase I and during the Phase II interviews and
observations. These messages were presented to a professional work group populated by local
community members who coordinate programs serving low-income, formula-feeding mothers
with young infants. During the professional work group, messages were ranked by perceived
importance using the nominal group process and then were refined based on input and group
discussion. This ranking and refining process was repeated among paraprofessionals working
directly with the target population. Focus groups with low-income, formula-feeding mothers
were held to further discuss and refine the messages. This process resulted in two final nutrition
education messages. The first message conveys that breastmilk and formula provide all of the
nutrients infants need until 4-6 months of age, and advises against modifying infant formula with
cereal and early introduction of solid foods. The second message focuses on preventing
overfeeding infants and the small size of the infant stomach. These messages will be combined to
form the intervention for Phase III, which will further test the developed messages along with
testing teaching strategies.








24

Message 1: Breastmilk and formula are filling
and provide everything your baby needs to be
healthy until 4 to 6 months.

! Formula and breastmilk are
packed with vitamins and
minerals. Adding cereal, juice,
or extra water takes away
important nutrients from your
baby.
! Cereal and juice have a lot of
sugar and dont have as much
fat and protein as formula or
breastmilk. Fat and protein help
your baby to stay fuller, longer.

Message 2: All babies have small stomachs.
Feed your baby small amounts more
frequently.

! All babies spit up, but
overfeeding may lead to
bellyaches and can make
spitting up worse.


! Save formula, time, and money
by making small amounts.
Small amounts heat up faster
and you waste less.



Phase III: The purpose of Phase III is to use a randomized-controlled study design to test the two
developed nutrition education messages by assessing infant formula preparation knowledge and
preliminary behavior changes as a result of an online intervention. Resources from University of
Tennessee Extension will be utilized to develop a strategic and effective online learning module.

The online learning modules are currently being finalized by the research team with the
assistance of resources available to the Co-PIs in University of Tennessee Extension. As
previously described, three online modules will be developed: intervention online module 1
(educational video), intervention online module 2 (educational video plus interactive segments),
and an online control module (educational sham video focusing on preparing the home for a
crawling infant). All modules will be followed by a short questionnaire in order to ensure
completion of the online segment, and modules will be designed to take no more than 10 minutes
to complete, but mothers will have no time restrictions. The online learning modules for the two
intervention groups will communicate the two nutrition education messages developed in Phase



23
II. Topics covered in the intervention modules will include the satiating effect of breastmilk and
infant formula and feeding age-appropriate amounts to young infants with small stomachs.

The two intervention modules will incorporate the same animation, and the messages will be
delivered by an animated infant. The only difference between the two intervention modules will
be the presence of interactive components in intervention module 2. For example, the mother
might have to choose the correct, age-specific, amount of formula to offer an infant after
receiving the education pertaining to the size of the infant stomach. She may then answer
questions about accurate formula preparation, given different ingredients to choose from, after
receiving education about the satiating effect of formula and breastmilk. If a mother chooses an
incorrect option, she will be corrected, provided with explanations, and prompted to repeat
response to the question until the correct answer is chosen. If she answers correctly, she will be
provided with an explanation for why her answer is correct. The interactive module will
designed so that the research team can determine which incorrect responses were chosen prior to
the mother choosing the correct response (if any) and how many times the mother answered
incorrectly (if applicable). The online control module will not address infant feeding or any
related topics that may indirectly influence maternal feeding behaviors. To reduce bias, the
control module will cover a topic pertinent for mothers of infants ~3 months of age, such as
safely preparing the home for a soon to be crawling infant. The control module will be strictly
educational with no interactive components.

Objective 1: Conduct a randomized-controlled trial, to determine if targeted nutrition education
messages, designed to increase compliance with infant feeding recommendations and delivered



26
in an online format (intervention groups 1 and 2), will result in knowledge and behavior change,
compared to messages unrelated to infant nutrition (control group), and to do so in a population
of low-income, formula-feeding mothers with infants less than 3 months of age.

Phase III recruitment: Research participants for this project will be WIC-eligible, formula-
feeding mothers (>16 years of age) with < 3 month old, healthy infants in the Appalachian region
of the US (will be screened for eligible zip codes). Parity is not an inclusion/exclusion criterion
for this study. Mothers will be recruited from one of several sources. The first source will be the
Knox County WIC clinic, via flyer distribution (Appendix I). Another recruiting source for
participants will be EFNEP, which will be coordinated by one of the Co-PIs working at
University of Tennessee Extension. Similar to previous phases, recruitment flyers (Appendix I)
will be distributed at local community health organizations serving the target population, such as
the Pregnancy Help Center, Helen Ross McNabb, and the Hope Resource Center. Also, online
recruitment will continue by posting recruitment advertisements on Facebook, Twitter, and
Craigslist. The research team has been successful with online recruiting during previous phases
of this project. A total of 90 mothers must be recruited (30 per group) in order to have a sample
size large enough to detect differences in infant-feeding behaviors, such as total ounces offered
and consumed. Recruitment will continue until this sample size is achieved.

Phase III detailed methods: Potential participants who contact the Infant, Child, and Adolescent
Nutrition (ICAN) Lab at The University of Tennessee, Department of Nutrition, will be screened
for eligibility. Eligible participants will be those who are primarily formula-feeding (offering no
more than 2 breastfeeds a day), using powdered or from-concentrate infant formula, and who are



27
low-income (based on 2012 2013 WIC eligibility guidelines). These standards will be revised
in accordance with the new version of WIC eligibility guidelines, which will be released in July
2013. Eligible participants will be mothers with infants who were normal birth weight (> 2500 g
or 5.5 lbs) and whose infants are free from any chronic health conditions affecting infant intake,
including but not limited to heart conditions and respiratory conditions. In addition, infants must
be < 2.5 months of age (76 days) at recruitment, as this will allow time for completion of the
online learning module before the infant is 3 months of age. Eligible participants must have a
reliable phone for communication of study activities and must have access to the internet. They
must also reside in the Appalachian region of the US, so they will be screened for eligible zip
codes. A screening tool similar to the ones from previous phases will be used (Appendix II).

2012-2013 WIC Eligibility Criteria
Persons in
Family or
Household Size
Annual Monthly
Twice-
Monthly
Bi-Weekly Weekly
1 $20,665 $1,723 $862 $795 $398
2 27,991 2,333 1,167 1,077 539
3 35,317 2,944 1,472 1,359 680
4 42,643 3,554 1,777 1,641 821
5 49,969 4,165 2,083 1,922 961
6 57,295 4,775 2,388 2,204 1,102
7 64,621 5,386 2,693 2,486 1,243
8 71,947 5,996 2,998 2,768 1,384
Each Add'l
Member Add
+$7,326 +611 +306 +282 +141


Upon determination of eligibility, a brief explanation of study activities will be given, and an
expression of interest by the participant will be obtained. Thereafter, two copies of the Consent
Form (Appendix IV) and 24 hour infant intake forms (Appendix V) will be mailed to the



28
potential participant, and participants will be called to confirm receipt. Upon receipt of the intake
forms, participants will be trained on how to accurately record infant intake and asked to do so
for 24 hours. At a time negotiated to be the most desirable for the participant, the participant will
begin recording the time and date that each bottle was prepared, the total amount of formula
prepared, whether and how much cereal was added, if other foods were added, how much
remained in the bottle upon termination of the feed, an estimate of how much was lost via spit-
up, and who fed the infant. Recording will continue for 24 hours. A similar instrument has been
successfully used in Phase I of this project, and the PI has extensive experience with this
methodology, specifically in the WIC-eligible population. Research assistants will call mothers
to collect infant intake data over the telephone. Participants will be asked to mail the completed
intake record and a signed Consent Form to the research lab, using a self-addressed, stamped
envelope (SASE) supplied by the research team. Participants will keep one copy of the Consent
Form for their personal records. Upon receipt of the completed intake record, mothers will be
randomly assigned to one of three groups: intervention online module 1 (educational video),
intervention online module 2 (educational video plus interactive segments), or the online control
module (educational sham video). Randomization will be completed by using a function in
Microsoft Excel, which allows for randomly selecting one of the three groups without over
sampling for one particular group. Upon completion of the baseline infant intake forms and
online module, participants will be compensated with a $10 gift card to a national discount
merchant, which will be mailed to the participant. Participants will also be mailed a second copy
of the blank 24 hour infant intake forms (Appendix VI) with the gift card. Within two weeks of
online module completion, participants will complete a second and final 24 hour infant intake
record, and will be asked to engage in a brief exit interview, over the telephone, to assess



29
knowledge retention and reaction to the online module. At this time, research assistants will once
again collect 24 hour infant intake data over the telephone. Participants will be asked to mail the
completed intake record to the research lab, using a self-addressed, stamped envelope (SASE)
supplied by the research team. Only participants from the two intervention groups will be asked
to complete the exit interview. Following the exit interview (if applicable) and after completing
the follow-up 24 hour infant intake record, participants in all three groups will be compensated
with the remaining $20 gift card to a national discount merchant, which will be mailed to them.
Only data on infant intake, formula preparation, and knowledge will be collected, placing the
participants at minimal risk when completing this study. In addition, all online modules will be
password protected, increasing confidentiality. The research assistants will assign each
participant with a unique user name and password in order to access the online modules. All data
will be collected at baseline (~2.5 months of infant age), and within 2 weeks of completing an
online module. The length of time from baseline to follow-up will be no more than 3 weeks.

Objective 2: Determine if messages, delivered using embedded interactive subcomponents
(intervention group 2), result in greater knowledge and behavior change, compared to a more
traditional slideshow format (intervention group 1).

Data analysis: The sample size of 30 participants per group was calculated based on literature
describing intake of normal, healthy infants at ~4 months of age (means and associated standard
deviations) [12, 50]. A power of 0.8 and a significance level of 0.05 were used in the sample size
calculation. SPSS (version 20.0) will be used for statistical analysis of baseline and follow-up



30
infant intake data. Statistical analyses will determine if there was a significant difference in
formula modifications and overall infant intake between groups.

After data collection, data will be cleaned to account for missing variables. Then, frequencies
and correlations will be calculated to determine if randomization was successful and if any
independent variables affected the outcome variables of ounces offered and consumed. If, for
example, infant age (days) is correlated with amount of infant formula offered (ounces), then
infant age would be a confounding variable, and would be accounted for in the forthcoming
statistical analyses. Furthermore, if by chance, one group was comprised of significantly more
male infants compared to the other two groups, despite randomization, and infant gender was
related to the outcome variables, then this would be accounted for in the upcoming analyses as
well. Following descriptive statistical analyses, the research team will compare the outcome
variables, ounces of infant formula offered and consumed, based on group assignment. This will
be completed by running a multivariate analysis of variance (MANOVA) test. This analysis will
determine if there were statistically significant differences in the ounces of infant formula
offered and consumed between groups. A subsequent post-hoc analysis will then determine
where the statistical differences occurred (ie: between which groups). Linear regression analyses
would be used to control for potential confounding variables.

These analyses will be used to determine if receipt of the message alone impacted behavior and
if differences were significant between the intervention group receiving just the educational
video compared to the intervention group receiving the educational video plus the interactive
components: thus, testing the effectiveness of the nutrition education messages and the



31
effectiveness of the different teaching strategies. As a secondary exploratory analysis, the
research team will look at differences in cereal use between groups based on group assignment.
This will not be a primary outcome tested, however, because the sample size for this project was
calculated based on infant intake data, not based on data for cereal usage. The research team
anticipates that the sample size might not be large enough to reach statistical significance for
differences in cereal use based on group assignment. However, this will be an interesting
outcome to explore to observe if the messages changed infant-feeding behaviors in regards to
addition of cereal to infant formula, and may be used as pilot data for future projects and
proposals.

Application of the Research Results: The results and online learning module will be made
available to community programs such as EFNEP and WIC and other professionals who work
with low-income, formula-feeding mothers with young infants. In addition, findings will be
presented at a national conference and published in a peer-reviewed journal.

2393'+'3#1*

Despite plans for successful recruitment strategies, the research team anticipates difficulties
recruiting WIC-eligible, formula-feeding mothers with < 3 month old, healthy infants. However,
recruitment has become less of a problem as the study has progressed. In addition, Phase III will
not include a home visit, most likely enhancing recruitment. Phase I and Phase II both required a
home visit, but Phase III will be primarily internet-based with brief telephone interaction.
Mothers will be able to complete study activities at a time and location that is convenient for
them. Therefore, the research team anticipates fewer drop-outs compared to previous phases. In



32
addition, the online data collection methodology allows the research team to reach a larger
geographic area than previous phases, because driving distance will not be a limiting factor for
study recruitment.


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2. Cgden CL, Carroll Mu, CurLln L8, Mcuowell MA, 1abak C!, llegal kM: reva|ence of overwe|ght
and obes|ty |n the Un|ted States, 1999-2004. !1,1 2006, 29S:1349-1333.
3. lranclscheLLl LA, Cenelhu vA: Cbes|ty-hypertens|on: an ongo|ng pandem|c. 2&. ! #$%& 3+/*.
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card|ovascu|ar d|sease. '4+ ! #/+(%)5/6* 3+-5 7-8/0%$ 2008, 1S:130-139.
3. WhlLaker 8C, WrlghL !A, epe MS, Seldel ku, uleLz WP: red|ct|ng obes|ty |n young adu|thood
from ch||dhood and parenta| obes|ty. 9 '&:$ ! ,-( 1997, 337:869-873.
6. Lrlksson !C, lorsen 1, 1uomllehLo !, Csmond C, 8arker u!: Lar|y ad|pos|ty rebound |n ch||dhood
and r|sk of 1ype 2 d|abetes |n adu|t ||fe. ;%/0-.)$):%/ 2003, 46:190-194.
7. lreedman uS, khan Lk, uleLz WP, Srlnlvasan S8, 8erenson CS: ke|at|onsh|p of ch||dhood obes|ty
to coronary heart d|sease r|sk factors |n adu|thood: the 8oga|usa neart Study. 3-(%/.+%*6 2001,
108:712-718.
8. Cng kk, Ahmed ML, LmmeLL M, reece MA, uunger u8: Assoc|at|on between postnata| catch-
up growth and obes|ty |n ch||dhood: prospect|ve cohort study. <,! 2000, 320:967-971.
9. SLeLLler n, Zemel 8S, kumanylka S, SLalllngs vA: Infant we|ght ga|n and ch||dhood overwe|ght
status |n a mu|t|center, cohort study. 3-(%/.+%*6 2002, 109:194-199.
10. !ames uC, Lessen 8: os|t|on of the Amer|can D|etet|c Assoc|at|on: promot|ng and support|ng
breastfeed|ng. ! 1= ;%-. 166)* 2009, 109:1926-1942.
11. Iacts for L|fe. 4Lh edlLlon: World PealLh CrganlzaLlon, 2010.
12. Pelnlg M!, nommsen LA, eerson !M, Lonnerdal 8, uewey kC: Intake and growth of breast-fed
and formu|a-fed |nfants |n re|at|on to the t|m|ng of |ntroduct|on of comp|ementary foods: the
DAkLING study. Dav|s Area kesearch on Lactat|on, Infant Nutr|t|on and Growth. 1*./ 3/-(%/.+
1993, 82:999-1006.
13. Ll 8, Magadla !, leln S8, Crummer-SLrawn LM: k|sk of bott|e-feed|ng for rap|d we|ght ga|n
dur|ng the f|rst year of ||fe. 1+*8 3-(%/.+ 1()$-6* ,-( 2012, 166:431-436.
14. Podges LA, !ohnson SL, Pughes SC, Popklnson !M, 8uLLe nl, llsher !C: Deve|opment of the
respons|veness to ch||d feed|ng cues sca|e. 1>>-.%.- 2013, 6S:210-219.
13. Ll 8, leln S8, Crummer-SLrawn LM: Assoc|at|on of breastfeed|ng |ntens|ty and bott|e-empty|ng
behav|ors at ear|y |nfancy w|th |nfants' r|sk for excess we|ght at |ate |nfancy. 3-(%/.+%*6 2008,
122 Supp| 2:S77-84.
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exposure |n pat|ents eva|uated for a||eged ch||d abuse and neg|ect. 3-(%/.+ '=-+: #/+- 2011,
27:490-493.
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34
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33
42. Case CM, Plno !: Cn||ne Nutr|t|on Lducat|on: Lnhanc|ng Cpportun|t|es for L|m|ted-kesource
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