Internist, diabetologist reflects on infant feeding’s role in diabetes outcomes

November is National Diabetes Awareness Month.  Dana Dabelea, MD, PhD is  co-chair of the SEARCH for Diabetes in Youth study and currently the principal investigator on nine federally funded grants. She is also the director of the Center for Lifecourse Epidemiology of Adiposity and Diabetes (or LEAD) and an active educator for students and fellows. This week on Our Milky Way, she shares fascinating and valuable insight on how infant feeding plays a role in diabetes outcomes.

Q: How did you become interested in maternal child health?

A: I was trained as an internist and diabetologist in Romania and worked primarily with adults, though I did see youth with type 1 diabetes. I later became a fellow at the Epidemiology and Field Studies Branch of the National Institutes of Health in Phoenix, Arizona.  There, we noticed that young American Indian children were developing diabetes that used to be seen only in adults – namely Type 2 diabetes. Since they were young (some as young as age 5) it seemed logical that something was happening very early in life that set them on this trajectory. We began to study the effect of having diabetes during pregnancy – called gestational diabetes or GDM – on the offspring of those pregnancies. It turned out that the recent rise in youth onset type 2 we had been seeing was almost completely explained by the increase in GDM among mothers. The realization that early life events had later consequences was what really got me started in this area.

Q: To date, what is your most fascinating discovery?

A: After our studies in Arizona, we showed in Denver that the effect of GDM was very similar among non-American Indian youth. That and other studies led us to ask what GDM does to the offspring to increase the risk of diabetes and obesity – we knew from Arizona studies that while genetics plays a small role, something was very specific to pregnancy. So I began a study of pregnant mothers and their offspring called Healthy Start that collects information from the mothers and children as well as biologic samples to study this question. We began studying fuels that fed the growing baby – such as fats of various types and sugars- all of which come through the placenta and umbilical cord to nourish the fetus. It turns out that fatter babies (measured with an instrument called the PedPod®) had mothers with higher glucose levels during pregnancy, even if these levels were still considered in the “normal” range. We followed the offspring and looked at what influence postnatal feeding had as well. It turns out that breast-feeding for at least 6 months largely reverses the effects of GDM on fatness in children.  I think this was exciting, since it meant that there are things that can be done very early in life that can reduce the later risk of obesity and diabetes. We continue to look for others. But there is one additional thing of great interest – in studies of stem cells grown from the umbilical cords of these babies by my basic science colleagues, they have shown that obese mothers unknowingly ‘program’ these stem cells to be more likely to turn into fat cells than muscle or bone cells – some of the first human evidence of a possible pathway that changes how an infant responds to their environment. This too is very fascinating!

Q: The SEARCH for Diabetes in Youth study has shown diabetes to disproportionately affect minority children. Can you please briefly discuss this health disparity?

A: You are correct for type 2 diabetes – that used to be called adult onset diabetes. Type 1 diabetes (juvenile diabetes) is actually most common among non-Hispanic white youth, although recently we are seeing increasing trends in minority group, especially Hispanics. There are several factors at work in type 2 diabetes, but we don’t yet know all of the story. First, a higher proportion of minority youth are overweight or obese, which is the major risk factor for later diabetes. Second, many of these are children are offspring of mothers who themselves have diabetes, GDM, or even just obesity as they enter pregnancy. Such women pass to their babies an increased susceptibility for obesity and diabetes, a phenomenon called the “vicious cycle” – where the risk of obesity and diabetes are passed to the next generation without involving genetics. Lack of breastfeeding, or only a short duration of breastfeeding likely also plays a role, since it appears that breastfeeding reduces both obesity and diabetes among offspring. There is likely also increased genetic among minorities, which is actively under study.

Q: It’s been found that research takes about 17 years before it’s integrated into policy and practice. Are you concerned about this phenomenon as it relates to the diabetes epidemic among youth in the U.S.?

A: It would be great if we could move more quickly from basic and epidemiologic research into public health and clinical action – and there has been progress in this area. Fueled by a National Institutes of Health funding strategy called “Clinical Translational Sciences Awards” to many institutions across the country, these awards specifically target moving science from the “bench” to “bedside” (clinical action) to the community (public health action). A factor that still affects the time to answers and action is that our epidemiologic studies of mother-child populations need to follow participants as they grow up to see what is happening. Thus, we may have a good guess (hypothesis) about what is happening, but it may take several years of follow-up to learn if we were right. This is also true of prevention efforts aimed at obesity and diabetes. Recent data suggest that the obesity epidemic may be leveling off, but whether this will last, or even reduce diabetes, remains unknown. So there is an inherent delay while the studies are being completed.

We can still recommend and test best practices as we know them today, even with incomplete knowledge. For example, we conducted a pilot randomized controlled trial of obesity prevention among American Indian children aged 7 to 10, called Tribal Turning Point. We found that a combination of parent-child sessions aimed at behavioral motivation for change, along with a toolbox of community activities, cooking classes and fun things for kids to do, resulted in lower weight gain among the group that got the intervention. We are expanding this study to both urban and rural American Indians with a larger sample size to see if we can replicate the results. This kind of work is aimed at helping stem the tide of the epidemic in the highest risk group – American Indians. But counter forces are strong – an abundance of calories, often of poor quality, the ease with which we can live without much physical activity and potential environmental factors such as air pollution and endocrine disrupting chemicals, are all promoting dangerous levels of obesity.

Q: Can you please explain the term transgenerational prevention strategy? How does infant feeding fit into this dialogue?

A: I mentioned the “vicious cycle” of transgenerational obesity and diabetes above. Let me explain this in terms of prevention. We know that mother’s obesity prior to pregnancy, her amount of weight gain during pregnancy, and whether or not she develops diabetes during pregnancy, all increase the risk of obesity in the next generation – her offspring. There is even data suggesting that this risk may be partially transmitted to her grandchildren as well. So any preventive intervention aimed at reducing maternal obesity, weight gain or GDM during pregnancy all have the potential to be trans-generationally preventive.

Infant breastfeeding is one important component of this strategy. As I mentioned previously, we found that breastfeeding greatly reduced the risk of obesity in the offspring, brought about from the mother developing GDM. One caveat – this is from observational data, and it really needs to be tested in a clinical trial before saying that we really know this works.

Q: You have found that “breastfeeding ameliorates increased adiposity of offspring born to mothers with gestational diabetes.” Is this due to the act of breastfeeding itself or the components of human milk? Both?

A: These are good questions. While I suspect that it is largely due to breastmilk components, there is limited data on this as it relates to obesity and diabetes prevention. The reason I suspect this is that banked breast milk appears to provide similar benefits. But again, this is largely my opinion at this point in time.

Q: Does the duration of breastfeeding seem to have an effect on diabetes prevention? How about exclusivity?

A: I think both are important. In our studies we calculate “breast-milk-months’. If a woman breastfeeds exclusively for three months, then breastfeeds about one-half time for the next six months, we call that six breast-milk months, since (exclusive X 3) + (1/2 time X 6) = (3 + 3) = 6 breast milk months. There are other combinations that also produce six or more breast-milk months. I think this helps mothers who have trouble continuing breast feeding exclusively on return to work or for other reasons, but continuing for longer at part-time appears to provide at least many of the benefits as they relate to obesity

Q: How does the introduction of complementary feeding affect diabetes outcomes?

A: A number of studies of the timing of introduction of cereals, cow’s milk, formula, and other solid foods, have been conducted in children at genetically high risk of developing type 1 diabetes. Summarized simply, since this is a complex set of studies, it appears that introduction of cereals or any solid food before 4 months increases the risk of type 1, and similarly introduction at six months or after of either of these also appears to increase risk. Importantly, introduction of cereals at or after six months while breastfeeding actually reduces risk. It is important to remember that these studies were done among children who are at high genetic risk for type 1, and it is not clear that these findings are true among most children who are not already at increased risk.

I am not aware of studies that have rigorously tested this for type 2 diabetes. However, early introduction of solid foods (before six months) have been associated with increased fatness and obesity in children.

Q: The U.S. has the worst maternal mortality rate in the developed world, and our infant mortality rate is deplorable too. What’s more, lactation and breastfeeding education, promotion, protection and support are severely lacking. Even so, are there noteworthy efforts you’d like to highlight that aim to resolve these tragic outcomes?

A: I think the most notable efforts started with Dr. David Olds here at the University of Colorado. A number of years ago his team began the Nurse-Family Partnership (also called the Nurse Home Visiting Program) where a nurse visits high risk pregnant mothers who may lack access to pregnancy care, may suffer from poverty, teen pregnancy, and other risk factors, and works with the mother (and father, if available) to teach them about healthy pregnancies and how to nurture their infant after birth, including breastfeeding assistance. This intervention has been tested in rigorous clinical trials in several US and international settings and has shown marked improvements in infant outcomes over many years. Today, Nurse-Family Partnership serves low-income, first-time moms and their babies in 42 states, the U.S. Virgin Islands and six Tribal communities. I believe the widespread utilization of this approach would go a long way toward improving both maternal and infant mortality and would increase breastfeeding.

Lactation counselor training changes PA’s life

Credit: Wrought Iron Photography

Tia L. Oliveri, MMS, PA-C, CLC maintains a long and admirable list of accomplishments: first generation college graduate, mother of two, committed volunteer, bilingual, former member of the Wake Forest University Cultural Diversity Committee, former Guilford County Health Department Maternity Services care provider and Catawba County Health Department Women’s health provider, to name a few.

Most recently, Oliveri completed The Lactation Counselor Training Course after what might be considered a twist of fate due to time and money constraints. Completing the CLC course ultimately helped her land her newest position as a physician’s assistant in San Antonio.

“Becoming a lactation professional is changing my life,” Oliveri says.

During a time of transition, Oliveri networked with Brian the Birth Guy who encouraged her to pursue The Lactation Counselor Training Course and connected her to the practice she’s with today. Oliveri’s approach is patient-centered.

“I want patients to know their experience is all about them,” she says.

Oliveri’s passions for maternal child health “kind of happened by accident,” she says.

“I worked in the ER…and men wouldn’t deal with the female issues,” Oliveri recalls a chauvinistic environment. Eventually, she was asked to work as a contractor for a health department in a poor town where she was the only health care provider. Oliveri remembers seeing 36 patients a day without a doctor.

It was an “exhausting” experience for Oliveri, and there are things she says she “can’t unsee,” like female circumcision.

Oliveri saw it her mission to serve the underserved; she sat at the hospital with a Patient of Color so that she was certain a provider would see her.

“I was thrown into [the work] and didn’t have a lot of help,” Oliveri says. Later, a midwife mentored Oliveri.

Especially while serving a refugee population, the CenteringPregnancy model proved to be an effective method in her practice. Oliveri points out that CenteringPregnancy offers a tribe to those who don’t otherwise have a support system and allows women to ask relevant questions. She notes that in this population, many of the women had never seen a doctor, so breastfeeding became ever-important as it increased their own and their babies’ survival rates. CenteringPregnancy offered a space for the expectant mothers to ask questions about breastfeeding as well as milk sharing and wet nursing, practices often present in refugee populations.

In her personal life, Oliveri endured breastfeeding challenges due to lack of proper support after the birth of her first child.

“I had a job that told me to pump in the bathroom,” Oliveri recalls. Her breastfeeding relationship with her son ended when he was six weeks old.

“I was super depressed,” Oliveri says.

When her daughter was born years later, “she breastfed like a champ and gained a lot of weight.”

At only two weeks old though, her daughter contracted severe bronchiolitis, a lung infection that causes inflammation and congestion in the bronchioles of the lung. The congestion made it challenging for her daughter to breastfeed.

Oliveri feeds her daughter her expressed milk during their hospital stay.
Credit: Wrought Iron Photography

At one point, “she turned blue at home,” Oliveri says. They rushed to the hospital where she found herself, two weeks postpartum, forced into the health care provider role. Oliveri fashioned maxi pads from baby diapers. During her daughter’s hospital stay, Oliveri dedicated to pumping. Despite the severity of her daughter’s illness, the doctor was impressed with her resolve and attributed her resilience to Oliveri’s milk. Today, her daughter is a thriving one-year-old.

Credit: Jamilla Walker of the Labor Ladies

Although Oliveri weaned her daughter months ago, she reports relactating during her recent CLC training.

“I felt a let down during the videos,” she says. Later, she says she discovered the mature milk. Oliveri not only found herself relactating during her CLC course, she led a belly dance to the “When you counsel” song in a 1950s Lucille Ball inspired dress. It is this effervescent energy, confidence and unwavering wherewithal that is sure to score Oliveri more on her list of accomplishments.

Breastfeeding-friendly designation program enhances child care services

Like many mothers anticipating their return to work just weeks after birth, a South Carolina mother began to transition her baby to formula under the assumption that it would make the transfer to daycare more simple. Upon enrollment into the child care center, a male director shared with the mother their dedication to breastfeeding.

The director referred the mother to their local WIC office and La Leche League group. Now the baby no longer receives artificial milk, only expressed mother’s milk.

This success story is a result of South Carolina Program for Infant/Toddler Care’s (SCPITC) Breastfeeding Friendly Child Care designation program which recognizes child care programs that promote, protect and support breastfeeding and equips child care providers– who aren’t necessarily lactation experts– with the knowledge to help mothers achieve their infant feeding goals.

Lucie Maguire Kramer, MS, RDN, CLC Program Coordinator, Medical Univ. of SC Children’s Health Charleston comments, “[The director] didn’t say, ‘I know exactly how you can pump enough milk for your baby. He said ‘let’s try it.’”

Bringing breastfeeding awareness to the child care setting was part of South Carolina Department of Social Services’ (DSS) goal to enhance services in 2015. Team members looked to Carolina Global Breastfeeding Institute’s (CGBI) The Carolina Breastfeeding-Friendly Child Care (BFCC) Initiative for a framework and translated the material in a way that would work for their state, Maguire Kramer explains.

SCPITC already had an infrastructure of infant toddler specialists implementing programs directly into the child care setting throughout the state; so offering a breastfeeding-friendly designation was another thing to add to “the menu” of ways to improve quality of care, Maguire Kramer puts it.

“We had a lot of buy-in from the beginning,” she says. Child care instructors were on board, and while their partnership with DSS is critical for funding, it also represents a state-level buy-in “that speaks volumes.”

There are currently 13 child care programs designated Breastfeeding-Friendly through the program, two on the horizon and at least ten in backlog which exceeds the team’s initial goal to designate ten programs by 2019.

“It is so meaningful to all of us,” Maguire Kramer says.

From start to finish, becoming designated takes three to five months. Adopted from CGBI’s BFCC, the designation process requires child care providers to journey through the Ten Steps to Breastfeeding Friendly Child Care, modeled after Baby-Friendly Hospital Initiative’s (BFHI) Ten Steps.

Once a program expresses interest in designation, the entire staff must commit to a 2.5 hour training through SCPITC. Training is free to all participants.

Here, they cover things like how to properly warm human milk, how to hold a breastfed baby and how to decipher feeding cues. Participants play an “agree/disagree” game where they discuss controversial topics like breastfeeding in public. Maguire Kramer explains that this format–again adopted from CGBI– allows child care providers to express their reservations and personal attitudes.

From here, instructors lead the group into a “true/false” game where they open the discussion to opinion versus fact. Personal opinions about breastfeeding are inevitable; no matter one’s experience, child care providers are expected to support breastfeeding as part of their job description, just as they are expected to change diapers, Maguire Kramer goes on to say.

Through the training, participants receive a packet of materials including educational materials to pass along to families and breastfeeding-friendly books and toys to be used in their classrooms, which aligns with Step 4: provide learning and play opportunities that normalize breastfeeding for children. Each child care program receives up to three nursing animal toys with magnetic nipples.

“It can be strange for some teachers to talk about breastfeeding,” Maguire Kramer begins. “The animals kind of help break that barrier.”

After reviewing a self-assessment action guide, programs may apply for designation.

The application review committee– comprised of a neonatologist, pediatricians, independent lactation consultant, child care program director, nutrition specialists, and others– conducts quarterly meetings where they discuss their rubric for acceptability, pass around pictures submitted by child care programs, and discuss ways programs can improve their applications. Once programs review comments by the committee and implement suggested updates in their classrooms, they become designated.

Child care programs are awarded a decal, and a letter is sent out statewide announcing their efforts. The Breastfeeding-Friendly Child Care Designation is good for three years with annual renewal requirements.

Creating community networks is important to the sustainability of breastfeeding support. Step 9 encourages child care programs to forge relationships with WIC clinics, La Leche League groups, and other local lactation support people.

The SCPITC Breastfeeding Friendly Child Care designation program itself collaborates with SCale Down and the South Carolina Birth Outcomes Initiative, as well as DSS as mentioned previously. These partnerships have allowed for significant developments; for instance, breastmilk feedings are reimbursable for child care programs through nutrition services, and unfinished breastmilk is to be returned to families to decide how to dispose of or use the milk.

You can visit the SCPITC Breastfeeding Friendly Child Care site here.

Nestlé Free Week combats aggressive industry

Breaking the Rules 2014 (BTR) is a 237-page monitoring report of 813 International Code of Marketing of Breast-Milk Substitutes (Code) violations from 81 countries collected between January 2011 and December 2013. What that amounts to: countless mothers’ and babies’ lives on the line.

Dr. Arun Gupta of the Breastfeeding Promotion Network of India (BPNI) and Manager-Communication & Campaigns IBFAN Asia/BPNI Nupur Bidla point out in an email that Nestlé is the biggest player in the artificial baby milk industry. Nestlé, a constant violator of the Code, aggressively markets baby foods contributing to the death and suffering of infants globally, they go on.

Tomorrow marks the start of Nestlé-Free Week (October 30 to November 5, 2017), a campaign intended to promote the Nestlé boycott. (Read Baby Milk Action’s briefing paper for a history of the campaign as well as Business Insider’s Every Parent Should Know The Scandalous History Of Infant Formula.)

As detailed on the Baby Milk Action webpage, participants are encouraged to take action several ways:

Campaigning works. For example, Nestlé changed its statement of support for breastfeeding in its response to boycotters during Nestlé-Free Week 2015 to bring it into line with WHO recommendations, as stated on Baby Milk Action’s website.

Gupta and Bidla point out other campaign merits. Mike and Patty from Baby Milk Action UK  take part in Nestlé shareholder  meetings and voice dissent. The boycott has stopped Nestlé from promoting complementary foods for children below 6 months of age, a change that took nine years. Campaign pressure led to Nestlé’s public statements on breastfeeding from “4 – 6 months” to  “2  years and beyond” in its 2013 report.

“The boycott holds Nestlé to account and forces it to make changes, while also keeping the issue in the public eye,” Gupta and Bidla reiterate.

Still, they go on, Nestlé indulges in greenwashing activities like hi-jacking World Breastfeeding Week (WBW), and continue to commit atrocious acts like obtaining patient information illegally.

“Observing this campaign becomes even more important,” urge Gupta and Bidla.

The boycott will continue until Nestlé accepts and complies with Baby Milk Action’s four-point plan for saving infant lives.

The plan states:

  1.       Nestlé must state in writing that it accepts that the International Code and the subsequent, relevant World Health Assembly Resolutions are minimum requirements for every country.
  2.       Nestlé must state in writing that it will make the required changes to bring its baby food marketing policy and practice into line with the International Code and Resolutions (i.e. end its strategy of denial and deception).
  3.       Baby Milk Action will take the statements to the International Nestlé Boycott Committee and suggest that representatives meet with Nestlé to discuss its timetable for making the required changes.
  4.       If IBFAN monitoring finds no Nestlé violations for 18 months, the boycott will be called off.

Gupta and Bidla add: Nestlé is also involved in exploitation of water resources (see Council of Canadians boycott call), treatment of dairy and coffee farmers, accusations of child slavery and labour in its cocoa supply chain and other issues (see report to the UN Global Compact office, 2009).

Visit this year’s campaign website here. Happy boycotting!

Banner and illustration source:

Fathers profoundly influence breastfeeding outcomes

At a WIC clinic a few miles north of Dallas in an immigrant community, a pregnant woman confided in a male peer counselor–part of the WIC Peer Dads Program— that she wanted to breastfeed her baby. Her boyfriend wasn’t at all interested in supporting this journey though. The counselor offered to speak to the father; the mother agreed, so the counselor called him just then. Ring, ring, ring. After introductions, this conversation ensued:

Counselor: We heard you have an issue with breastfeeding.

Father: So you are calling me to convince me that breastmilk is better?

Counselor: No, I just want to give you some information.

Father: I will come to your office. You prove to me that breastfeeding is better.

The next morning, the father arrived at the clinic before it opened.

Source: United States Breastfeeding Committee

“Tell me why she should breastfeed,” the father demanded of the counselor, who was feeling rather intimidated.

The counselor replied: Forty-five years down the road, your unborn son is guaranteed to be the president of the United States. What are you going to do today?

The father looked at him perplexed and laughed.

“You tell me,” his retort.

The counselor handed him a sheet of paper instructing him to write these letters: B-R-E-A-S-T-F-E-E-D, providing corresponding ‘benefits’ to breastfeeding with each letter. (B is for bonding and so on.)

“Dude! You’re good,” the father exclaimed, changing his demeanor. “Ok, you got me,” he agreed to open his mind to breastfeeding.

Mwamba demonstrates ways to hold baby during a class for parents .

Muswamba Mwamba, MS, MPH, IBCLC, RLC, a public health nutritionist, told me this story during a fascinating interview for Our Milky Way. Having worked in nutrition for nearly three decades, Mwamba has acquired a brilliance for carefully interpreting and reflecting on the stories of the people he encounters.

“The guy was bold,” Mwamba remembers of the father. In fact, the father planned to dump his pregnant girlfriend after she became pregnant.

“A lot of men may know how to change diapers, know how to carry the baby,” Mwamba begins. “But something they don’t know is how to befriend the woman. When they don’t know, they run away.”

This couple’s story took a happy turn. Mwamba reports that they married with their peer counselor as their witness.

“You saved my relationship,” the father heartfully expressed his gratitude to the counselor.

After serving nearly 10 years as the City of Dallas WIC Peer Dads Program Coordinator, Mwamba is currently Director to Reaching Our Brothers Everywhere (ROBE), a descendant of Reaching Our Sisters Everywhere (ROSE). ROSE and ROBE are dedicated to reducing breastfeeding disparities among African Americans.

But Mwamba’s career goals didn’t always point specifically to breastfeeding. Always fascinated by nutrition as the foundation of health, Mwamba found himself in a microbiology lab in Belgium completing two master’s degrees in Food Science and Technology and Agricultural Engineering & Human Nutrition.

He quickly realized that he “prefers people to mice.”  So when Mwamba, a Congolese native, came to the States in 1997, he searched for a doctoral program that might better fit his passion for behavioral science. Mwamba made his way to Columbia University in 1999 where he studied Nutrition Education, exploring the intersections between science and behavior, environment and genes.

At the time, Mwamba remembers being happy to be in the U.S. but in retrospect, he says he realizes he was naive about racial disparities in health care. It wasn’t until later that he learned about the historical forces in the United States that make health disparities a reality.

Mwamba pictured with colleagues Brenda Reyes and Mona Liza Hamlin.

“Thinking backward, I didn’t see anyone in my class who was local; they were all caucasian female,” Mwamba recalls.

Except for himself of course, the only Black man, and an immigrant at that. Institutions have policies written to encourage diversity, Mwamba begins.  

“When they see Black, they see diversity,” he says. These policies ignore the heterogeneity of Black culture.

“As an immigrant, I was privileged when I got the scholarship,” he explains. Mwamba already held two master’s degrees and had seen the world. His experience was vastly different from those of the People of Color living in the community he was to serve.

“We have the same color of skin, but not the same stories, not the same backgrounds,” he reiterates.  

Mwamba adds that African immigrants are the fastest growing and most educated group of immigrants in the U.S. From 2000 to 2004, four percent of immigrants in the U.S. were African. Today, African immigrants account for 8 to 10 percent, he reports.

Mwamba stresses, money needs to be properly allocated to serve those in need.

“The gap is increasing within the [Black] community,” he says of health disparities. “…Diversity is not the solution for the disparity.”

Little did he know, his opportunity to work to close this gap and to give a voice to “the folks who think they have nothing to say because nobody ever listened to them” was just around the corner.

Discussing a course’s simplicity with his professor at Columbia one day, a woman from Ghana happened to be listening in on their conversation. She was the director of a WIC clinic and recruited Mwamba as a nutritionist one year later.

Mwamba was instantly fascinated by the components of artificial baby milk, inspired by the questions his clients asked, and curious about the effects of clients’ infant feeding experiences.

He noticed that mothers who fed their babies formula often came to the clinic with various complaints.

Then there was a woman he remembers who exclusively breastfed her baby for one year. When she came in, she seemed happy and had only one concern: Why hadn’t her period returned yet?

Mwamba needed to do some research. He read everything he could. He worked to develop appropriate language to discuss infant feeding with his clients.

He began to grasp delicate intricacies like the sexualization of breasts in America. One client in particular expressed concern about her baby touching her “boobs.” (As a self-taught Anglophone, Mwamba never encountered “boobs” in his literature.)

As he discovered more and more about breastfeeding, he shared the information with his team. Mwamba became a breastfeeding champion.

In 2003, Mwamba moved to a WIC clinic in Dallas. Here, he received structured training through breastfeeding modules.

In 2005 he and his wife, an OB/GYN, welcomed their first babies to the world, a three pound baby girl and a four pound baby boy. Over the next couple of years, they added three more children to their family. Mwamba spent several months at home with their infants.

Source: United States Breastfeeding Committee

Aware that a primary reason a mother chooses not to breastfeed is her perception of the father’s attitude toward infant feeding, Mwamba launched the City of Dallas WIC Peer Dad program. The program was promptly a success.

Perhaps most importantly, the clinic was already breastfeeding-friendly. Secondly, there were several men already working in the clinic– including Mwamba who understood rich, complex immigrant culture. As Kimberly Seals Allers puts it, “The experience of being interpreted is different from the experience of being understood.”

Mwamba and his team worked by the motto Prepare, Equip and Empower.

They validated men in their role as a father and gave them tools like how to speak up and say, “Hello, I’m here!” when others failed to recognize their presence.

“Equip the father with tools they can use today,” Mwamba begins. “If you start talking about the future, they won’t get the information. Meet people where they are.”

Mwamba started conversations with his clients in an attempt to get fathers to connect with their relationships with their fathers; Emotion is more valuable than hard science.

For instance Mwamba describes one client, the father of five children, who “was over six feet tall with dreadlocks and his underwear showing.” He remembers this client had an air about him: I’m the dude here.

Mwamba discussed with him his role to protect and provide for his family. He asked, “Is there a man you look up to?” The father reported that he had a close relationship with his big brother. Mwamba wondered if he looked to his own father as a hero, or if he would change his relationship with his father. At that, the father’s voice cracked. He began to sob. This father was in the position to reflect on his role as a father and accept the influence he would have on his family.  And a father’s role is profound. When he is indifferent about breastfeeding, mothers will breastfeed 26 percent of the time; if he is pro-breastfeeding, mothers will breastfeed 98 percent of the time.

Tapping into the generalization that “men like the brag,” Mwamba and his colleagues encouraged their clients to spread forth their infant feeding experiences into their communities.

In his years working with the peer counselor program, Mwamba listened to stories that seriously question one’s capacity to have hope in humanity. In these moments, he didn’t have a script. Whatever rage he felt, whatever sympathy he bestowed, he couldn’t find a book or a module to learn how to accept the rawness, the vulnerability of his clients. Instead, Mwamba offered his presence and his willingness to listen, learn and understand.