maternal gestational weight gain and offspring risk for childhood overweight or obesity

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OBSTETRICS

Maternal gestational weight gain and offspring risk forchildhood overweight or obesitySneha B. Sridhar, MPH; Jeanne Darbinian, MPH; Samantha F. Ehrlich, PhD; Margot A. Markman, BA;Erica P. Gunderson, PhD; Assiamira Ferrara, MD, PhD; Monique M. Hedderson, PhD

OBJECTIVE: The objective of the study was to evaluate the association maternal prepregnancy BMI, race/ethnicity, age at delivery, education,
between gestational weight gain, per the 2009 Institute of Medicine(IOM) recommendations, and offspring overweight/obesity at 2-5 yearsof age.
STUDY DESIGN: This was a prospective cohort study of 4145 womenwho completed a health survey (2007-2009) and subsequentlydelivered a singleton at Kaiser Permanente Northern California(2007-2010). Childhood overweight/obesity was defined as a bodymass index (BMI) z-score of the 85th percentile or greater of theCenters for Disease Control and Prevention child growth standards.Gestational weight gain was categorized according to the 2009 IOMrecommendations. Logistic regression was used; meeting the IOMrecommendations was the referent.

RESULTS: Exceeding the IOM recommendations was associated with a46% increase in odds of having an overweight/obese child (odds ratio[OR], 1.46; 95% confidence interval [CI], 1.17e1.83), after adjusting for

From the Division of Research, Kaiser Permanente Northern California, Oakla

Received Oct. 13, 2013; revised Jan. 31, 2014; accepted Feb. 26, 2014.

This research was supported by a research grant (R40MC21515) from the HServices Administration (M.M.H.).

The authors report no conflict of interest.

Presented in poster format at the 140th annual meeting of the American PubSan Francisco, CA, Oct. 27-31, 2012.

Reprints: Sneha Sridhar, MPH, Division of Research, 2000 Broadway, [email protected].

0002-9378/$36.00 � ª 2014 Mosby, Inc. All rights reserved. � http://dx.doi.org/10.1

child age, birthweight, gestational age at delivery, gestational diabetes,parity, infant sex, total metabolic equivalents, and dietary pattern. TheOR (95% CI) for childhood overweight/obesity among women gainingbelow the IOM recommendations was 1.23 (0.88e1.71). The associ-ations between gaining outside the IOM recommendations and child-hood obesity were stronger among women with a normal prepregnancyBMI (OR, 1.63; 95% CI, 1.03e2.57) (below); OR, 1.79; 95% CI,1.32e2.43) (exceeded).

CONCLUSION: Gestational weight gain outside the IOM recommen-dations is associated with increased odds of childhood overweight/obesity, independent of several potential confounders and mediators.Gestational weight gain had a greater impact on childhood overweight/obesity among normal-weight women, suggesting that the effect maybe independent of genetic predictors of obesity.

Key words: childhood obesity, gestational weight gain

Cite this article as: Sridhar SB, Darbinian J, Ehrlich SF, et al. Maternal gestational weight gain and offspring risk for childhood overweight or obesity. Am J Obstet Gynecol2014;210:xx-xx.

estational weight gain has signifi-
G cant health implications for boththe mother and her infant. Excess ges-tational weight gain has been associatedwith increased risk of gestational dia-betes, cesarean section, medically indi-cated preterm delivery, and maternalpostpartum weight retention,1-4 whereasinadequate gestational weight gain in-creases the risk of small for gestationalage infants, low birthweight, and spon-taneous preterm birth.5-7 In the short
term, gestational weight gain is associatedwith fetal growth and appears to bepositively correlated with birthweight,independent of genetic factors.8

Intrauterine exposure to inadequateor excess gestational weight gain mayalso have a lasting impact on offspringbody weight in childhood and beyond.Gestational weight gain may result indevelopmental programming of laterchildhood weight because of permanentalterations inmetabolism, similar to what

nd, CA.

ealth Resources and

lic Health Association,

nd, CA 94612-2304.

016/j.ajog.2014.02.030

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has been observed for maternal diabetesmellitus.9

Obese children are more likely to havea myriad of health problems in child-hood, and they are more likely to remainobese into adulthood.10 Efforts to pre-vent overweight and obesity should startearly in life to prevent potential adverseeffects on multiple organ systems inchildren.11 Given that the prevalence ofobesity among children has more thantripled since 1980 and currently in theUnited States, approximately 17% ofchildren and adolescents aged 2-19 yearsare obese,12 there is a clear need toidentify modifiable risk factors.

Out of growing concern for the obesityepidemic, in 2009 the Institute of Medi-cine (IOM) set new guidelines for gesta-tional weight gain based on prepregnancybody mass index.13 The guidelines in-clude ranges for both total weight gainand trimester-specific weekly rates ofweight gain for women carrying a singlebaby. The IOM report identified specific

erican Journal of Obstetrics & Gynecology 1.e1

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areas of focus to fill major gaps in re-search, and 1 such area was more studiesassessing the impact of gestational weightgain on child health outcomes using theupdated guidelines.

We sought to prospectively evaluatethe association between gestationalweightgain, per the 2009 IOM recommenda-tions, and subsequent overweight/obesityamong children aged 2-5 years in a largemultiethnic cohort study of 4145 womenwho had completed a detailed healthsurvey before pregnancy (between 2007and 2009) and had a subsequent singletonlive birth at Kaiser Permanente NorthernCalifornia (between 2007 and 2010).

MATERIALS AND METHODS

The study setting was Kaiser Perma-nente Northern California (KPNC), alarge group practice prepaid health planthat provides comprehensive medicalservices to members residing in a 14county region of Northern California(approximately 30% of the surroundingpopulation). The demographic, racial/ethnic, and socioeconomic makeup ofthe KPNC membership is well repre-sentative of the population residing inthe same geographic area, except thatthe very poor and the very wealthy areunderrepresented.14,15

Cohort identificationThe cohort consisted of KPNCmemberswho completed a survey as part of theKaiser Permanente Research Programon Genes, Environment, and Health(RPGEH) between 2007 and 2009 andsubsequently delivered a live-born sin-gleton at KPNC between 2007 and 2010.Pregnancies were identified throughthe KPNC Pregnancy Glucose ToleranceRegistry, an ongoing registry that iden-tifies all pregnancies reaching the secondtrimester and that has previously beendescribed in detail.16

The RPGEH survey was initiallymailed to adult members (aged >18years) of KPNC in February 2007.Approximately 400,000 memberscompleted the survey and providedconsent for linking the survey data totheir electronic medical record (EMR),of which 57,100 were reproductive-agedwomen. The survey contained detailed

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information on pregravid factors in-cluding body mass index (BMI), alcoholconsumption, medical and reproductivehistory, smoking, diet, and physicalactivity.In general, this cohort of RPGEH

survey responders who became pregnantwas representative of the pregnanciesoccurring within Kaiser PermanenteNorthern California membership: 53%of the RPGEH cohort were from racial/ethnic minority groups compared with58% among all KPNC pregnancies.There was slightly lower representationof African Americans (4.4% vs 6.6% inthe KPNC pregnant population).Among women who completed the

RPGEH survey and had a subsequentpregnancy in KPNC, we identified 5967mother/child pairs resulting in a sin-gleton live birth with a child’s height andweightmeasurements taken at 13monthsof age or older. If awoman hadmore than1 pregnancy, we selected the first one afterthe RPGEH survey. We then restricted tomother/child pairs in which the child wasaged 2 years or older at the time of themost recent weight and height measure-ment (n¼ 4505).We excluded pairs if themother was missing data on gestationalweight gain (n ¼ 4151). We then limitedthe cohort to those who had completedata on gestational age at delivery,resulting in a final analytic cohort of 4145mother/child pairs.This study was approved by the Kaiser

Foundation Research Institute Institu-tional Review Board and the State ofCalifornia Committee for the Protectionof Human Subjects.

Maternal characteristicsWe obtained the following maternalcharacteristics from the RPGEH survey:self-reported maternal race/ethnicity([1], non-Hispanic white, [2] AfricanAmerican, [3] Asian, [4] Hispanic, and[5] unknown) and educational attain-ment (in years).

Prepregnancy dietary patternThe RPGEH survey included 20 foodcategories, including sugar-sweetenedbeverages. To identify major prepreg-nancy dietary patterns, principal com-ponents analysis was used on the 20

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foods to identify factors that accountedfor much of the variance. The foodgroups (factors) were rotated using anorthogonal transformation, resulting inuncorrelated, independent factors. Thefactor score for each factor (pattern) wascalculated by summing intakes of foodgroups weighted by factor loading, andeach individual was assigned a score foreach identified pattern. Individuals witha high score for a pattern compared withindividuals with lower scores have astronger tendency to follow that pattern.The scores were then categorized bytertiles.

We identified 2 distinct dietary pat-terns: prudent andWestern. Prudent dietis characterized by consumption of thefollowing food groups: vegetables, fruits,whole grains, nuts/seeds, and beans. AWestern diet is characterized by theconsumption of processed meats, bakedgoods, whole eggs, beef, pork, lamb, deep-fried foods, margarine, and soft drinks.

Prepregnancy physical activityThe volume of total metabolic equiva-lent (METs) was calculated as minutesper week based on 4 questions.

Gestational diabetesGestational diabetes (GDM) wasassessed through the KPNC PregnancyGlucose Tolerance Registry17 anddefined as having at least 2 plasmaglucose values on the 100 g, 3 hour oralglucose tolerance test meeting orexceeding the Carpenter-Coustanthresholds (fasting: 95 mg/dL, 1 hour:180 mg/dL, 2 hours: 155 mg/dL, 3 hours:140 mg/dL).

Exposure ascertainmentPrepregnancy weight was a measuredweight obtained before pregnancy(within 12 months of the last menstrualperiod) when available in the EMR(90%) or self-reported prepregnancyweight assessed at the first prenatal visit,also assessed via EMR. PrepregnancyBMI was calculated as prepregnancyweight (kilograms) divided by height(meters) squared. BMI categories werecreated in accordance with the 2009IOM gestational weight gain recom-mendations as follows: underweight

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TABLE 1Characteristics of the maternal/child cohort

Characteristic

Below IOMrecommendations(n [ 452)

Met IOMrecommendations(n [ 947)

Exceeded IOMrecommendations(n [ 2746) P value

Maternal, mean � SD or n (%)

Age at delivery, y 33.4 � 5.1 33.5 � 4.7 32.5 � 4.8 < .01

18-24 20 (4.4) 24 (2.5) 140 (5.1)

25-29 80 (17.7) 163 (17.2) 567 (20.6)

30-34 160 (35.4) 362 (38.2) 1060 (38.6)

35-39 137 (30.3) 302 (31.9) 783 (28.5)

�40 55 (12.2) 96 (10.1) 196 (7.1)

Education, y < .01

�12 59 (13.1) 57 (6.0) 227 (8.3)

13-15 97 (21.5) 186 (19.6) 533 (19.4)

�16 275 (60.8) 657 (69.4) 1845 (67.2)

Unknown 21 (4.6) 47 (5.0) 141 (5.1)

Race/ethnicity < .01

Non-Hispanic white 190 (42.0) 444 (46.9) 1492 (54.3)

African American 33 (7.3) 31 (3.3) 107 (3.9)

Asian 132 (29.2) 248 (26.2) 536 (19.5)

Hispanic 77 (17.0) 178 (18.8) 460 (16.8)

Unknown 20 (4.4) 46 (4.9) 151 (5.5)

Parity < .01

0 124 (27.4) 245 (25.9) 914 (33.3)

1 210 (46.5) 482 (50.9) 1332 (48.5)

�2 118 (26.1) 216 (22.8) 484 (17.6)

Unknown 0 (0.0) 4 (0.4) 16 (0.6)

Prepregnancy BMI, kg/m2 27.9 � 7.9 25.2 � 5.7 25.7 � 5.2 < .01

<24.9 228 (50.5) 611 (64.6) 1,467 (53.4)

25.0-29.9 80 (17.7) 173 (18.3) 817 (29.8)

�30.0 144 (31.9) 163 (17.2) 462 (16.8)

Had gestational diabetes 76 (16.8) 75 (7.9) 139 (5.1) < .01

Volume of physical activity,MET min/wk

637.7 � 844.3 735.3 � 891.8 785.3 � 895.0 < .01

Child, mean � SD or n (%)

Male infant sex 216 (47.8) 481 (50.8) 1452 (52.9) .10

Infant’s gestational age at delivery 38.7 � 1.7 38.8 � 1.8 38.9 � 1.7 .03

<37 wks of gestational age at birth 35 (7.7) 75 (7.9) 178 (6.5) .25

Infant’s birthweight, g 3231 � 528.3 3344 � 540.9 3475 � 555.2 < .01

Macrosomia (birthweight >4000 g) 28 (6.2) 79 (8.3) 411 (15.0) < .01

Birthweight for gestational age < .01

Small for gestational age 58 (12.8) 96 (10.1) 194 (7.1)

Sridhar. Gestational weight gain and childhood obesity. Am J Obstet Gynecol 2014. (continued)

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TABLE 1Characteristics of the maternal/child cohort (continued)

Characteristic

Below IOMrecommendations(n [ 452)

Met IOMrecommendations(n [ 947)

Exceeded IOMrecommendations(n [ 2746) P value

Appropriate for gestational age 368 (81.4) 777 (82.0) 2206 (80.3)

Large for gestational age 21 (4.6) 63 (6.7) 329 (12.0)

Intrauterine growth restriction 16 (3.9) 15 (1.7) 31 (1.2) < .01

Overweight child (85th percentileBMI or less z-score <95th percentile)

51 (11.3) 74 (7.8) 365 (13.3) < .01

Obese child (BMI z-score �95thpercentile)

37 (8.2) 63 (6.7) 196 (7.1) < .01

Child’s age at height/weightmeasurement, mo

37.2 � 8.7 37.8 � 9.1 38.0 � 9.1 .29

BMI z-score 0.1 � 1.2 0.0 � 1.1 0.2 � 1.1 < .01

BMI, body mass index; IOM, Institute of Medicine; MET, metabolic equivalent.

Sridhar. Gestational weight gain and childhood obesity. Am J Obstet Gynecol 2014.


(<18.5 kg/m2), normal weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (�30.0 kg/m2). Given thesmall proportion of women who wereunderweight (1.9%), the underweightand normal-weight categories werecombined into 1 category (<24.9 kg/m2).

Total gestational weight gain wascalculated as the difference between thelast measured pregnancy weight andprepregnancy weight, in kilograms. Thelast pregnancy weight, obtained from theEMR, was the final predelivery weightand had to be measured no more than 4weeks before delivery to be included inthe analysis. Total gestational weight gainwas categorized according to the 2009IOM gestational weight gain recom-mendations (below, met, exceeded).13

The total rate of gestational weight gainper week during pregnancy (in kilo-grams) was calculated as the total gesta-tional weight gain divided by the weeksof gestation attained at the last preg-nancy weight measurement.

Offspring characteristicsBirthweight for gestational age was cate-gorized according to the study pop-ulation’s race/ethnicity- and gestationalageespecific birthweight distribution asfollows: large for gestational age if birthweight greater than the 90th percentile,small for gestational age if birthweight


was less than the 10th percentile, andappropriate for gestational age if birth-weight between the 10th and 90th per-centiles, inclusive. Sex, height, andweightdata for the children were obtained fromthe EMR. Children were classified asoverweight or obese if their BMI z-scoremet or exceeded the 85th percentile of theCenters for Disease Control and Preven-tion child growth standards, based on ageand sex.18 International Classification ofDiseases, ninth revision, delivery codes(764.x or 565.x [possible intrauterinegrowth restriction]) in our EMR wereused to identify infants with intrauterinegrowth restriction.

Statistical analysisUnconditional logistic regression analy-sis was used to obtain odds ratios (ORs)and confidence intervals (CIs) esti-mating the odds of subsequent child-hood overweight-obesity associatedwith gestational weight gain. For modelsexamining the IOM recommendationsas the exposure, we estimated the oddsof childhood overweight/obesity associ-ated with exceeding and gaining belowthe recommendations, as comparedwith meeting the recommendations. Fortotal gestational weight gain per week,we also categorized women into tertiles;those in the lowest tertile served as thereference group.

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Variables evaluated for confoundingincluded those of a priori interest(maternal age at delivery, race/ethnicity,prepregnancy BMI (kilograms per squaremeter), child age, preterm birth (<37weeks’ gestation), maternal education,parity, infant sex, volume of physical ac-tivity [mean MET minutes per week],and maternal prudent pattern diet).

To assess confounding, we enteredcovariates into a logistic regressionmodel one at a time and then comparedthe adjusted and unadjustedORs.19 Finallogistic regression models included thevariables that were evaluated for con-founding and further adjusted forbirthweight and maternal pregnancyglycemia (defined as GDM [yes or no]),which may be mediators of the gesta-tional weight gain and childhood over-weight/obesity association.20

We initially examined associationsstratified by the 4 levels of BMI categoryused for the IOM recommendations;however, given that results were similarfor overweight and obese women whenstratifying by prepregnancy BMI, the 2categories were combined. In addition,we had a very small percentage ofwomen who were in the underweightcategory (1.9%).

To assess the potential modifying ef-fects of prepregnancy BMI (�25 kg/m2

vs <25 kg/m2), we included appropriate

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TABLE 2ORs and 95% CIs for childhood overweight/obesity at 2-5 years of ageassociated with maternal gestational weight gain

Pregnancy risk factor

Unconditional logistic regression models, OR (95% CI)

CrudeMultivariableadjusteda

Multivariableadjustedb

IOM gestational weight gain recommendations

Below 1.43 (1.06e1.92) 1.12 (0.82e1.53) 1.23 (0.88e1.71)

Met 1.00 1.00 1.00

Exceeded 1.52 (1.24e1.86) 1.51 (1.23e1.87) 1.46 (1.17e1.83)

Rate of gestational weight gain, kg/wk

Tertile 1 (e0.43 to 0.30) 1.00 1.00 1.00

Tertile 2 (0.30-0.42) 0.93 (0.77e1.13) 1.32 (1.07e1.62) 1.27 (1.02e1.58)

Tertile 3 (0.42-0.99) 1.11 (0.92e1.34) 1.53 (1.25e1.88) 1.38 (1.10e1.72)

BMI, body mass index; CI, confidence interval; IOM, Institute of Medicine; MET, metabolic equivalent; OR, odds ratio.

a Adjusted for maternal age at delivery, education, prepregnancy BMI (kg/m2), and race/ethnicity; b Adjusted for maternal ageat delivery, education, prepregnancy BMI, race/ethnicity, child’s age, birthweight (small for gestational age, appropriate forgestational age [referent], large for gestational age), gestational weeks at delivery (<37 weeks vs >37 weeks), maternalglucose tolerance status (gestational diabetes [yes vs no]), parity, infant sex, tertile of total MET minutes per week, and tertileof dietary pattern score.



cross-product (interaction) terms inregression models. Finally, the followingsensitivity analyses were conducted: (1)restricting to those with an appropriatefor gestational age infant, and (2)excluding those with self-reportedweights. SAS version 9.1 (SAS InstituteInc, Cary, NC) was used for all analyses.

RESULTS

Table 1 displays the characteristics ofthe cohort by being below, meeting, orexceeding the IOM gestational weightgain recommendations; 10.9% fellbelow, 22.8% met, and 66.2% exceededthe recommendations. Women were, onaverage, 33 years old at delivery. Thecohort was racially diverse; only 51%were non-Hispanic white. Women whoexceeded the IOM recommendationswere more likely to be white, nullipa-rous, and to be overweight prior topregnancy. Women who were below theIOM recommendations were more likelyto be Asian or African American, to have2 or more children, and to be obesebefore pregnancy. Children were, onaverage, approximately 3 years old whenheight and weight were assessed.

Children of mothers who exceededthe IOM recommendations were largerat birth, on average, than those whosemothers met or were below the rec-ommendations (3475 g vs 3344 and3231 g, respectively; P < .01) and weremore than twice as likely to be macro-somic (15.0% among women whoexceeded, compared with 8.3% whomet and 6.2% who were below therecommendations).

Children of women who exceeded theIOM recommendations were morelikely to be overweight or obese at 2-5years of age (20.4% vs 14.5% [met] and19.5% [below]; P < .01). There weremore children with intrauterine growthrestriction born to mothers who werebelow the IOM recommendationscompared with those who met orexceeded the recommendations (3.9%vs 1.7% [met] and 1.2% [exceeded];P < .01).

Table 2 shows the ORs and 95% CIsfor childhood overweight/obesity at 2-5years of age. Women whose gestationalweight gain exceeded the IOM

recommendations were more likely tohave an overweight/obese child, afteradjusting for maternal age at delivery,education, prepregnancy BMI, and race/ethnicity (OR, 1.51; 95%CI, 1.23e1.87),compared with women who met theIOM recommendations.After further adjusting for child age,

parity, infant sex, exercise (tertile of totalMETminutes per week), and diet (tertileof prudent dietary pattern score) aswell as factors that may be mediatorsbetween gestational weight gain andchildhood obesity (maternal glucosetolerance status [GDM (yes vs. no)],birthweight, and gestational weeks atdelivery), the association was attenuatedbut remained significant (OR, 1.46; 95%CI, 1.17e1.83). The association betweengaining below the IOM recommenda-tions and increased odds of childhoodoverweight/obesity did not reach statis-tical significance.Women in the middle and highest

tertile of gestational weight gain (com-pared with the lowest tertile, respec-tively) were also more likely to have anoverweight/obese child after adjustingfor maternal age at delivery, education,prepregnancy BMI, and race/ethnicity

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(OR, 1.32, 95% CI, 1.07e1.62 [middle];OR, 1.53, 95% CI, 1.25e1.88 [highest]).In the fully adjusted model, the resultswere again attenuated but remainedsignificant.

There was significant interaction byprepregnancy BMI (�25 kg/m2 vs <25kg/m2) (P ¼ .017), and the associationswith being below and exceeding the IOMrecommendations were stronger forwomen who were of normal weight(BMI<25 kg/m2) before pregnancy thanin overweight/obese women (BMI �25kg/m2) (Figure), after adjusting formaternal age at delivery, education, andrace/ethnicity.

When stratified by the category ofbirthweight (small for gestational age,appropriate for gestational age, and largefor gestational age), the associationbetween the excess gestational weightgain and childhood overweight/obesityremained significant among offspringborn appropriate for gestational age(n¼ 3351; OR, 1.57; 95%CI, 1.23e2.01)(data not shown).

Results were also similar for thesensitivity analysis that was restricted towomen with a measured weight (n ¼3890) and for the sensitivity analysis that


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FIGUREGestational weight gain and childhood overweight/obesity, byprepregnancy BMI

Adjusted ORs and 95% CIs associated with childhood overweight/obesity, by prepregnancy BMI (BMI

<25 kg/m2 vs BMI �25 kg/m2).

BMI, body mass index; CI, confidence interval; OR, odds ratio.



restricted to the 811 mother/child pairswhose child was 4 years old or older(data not shown).

COMMENT

The majority of women in this cohortstudy exceeded the 2009 IOM gesta-tional weight gain recommendations.Women who exceeded them were 46%more likely to have a child who wasoverweight or obese at 2-5 years of age,independent of several covariates andmediating factors. There was also a trendof increasing risk of childhood over-weight/obesity with an increasing rate ofgestational weight gain. The impact ofinappropriate gestational weight gain,either above or below the IOM recom-mendations, on childhood overweight/obesity appeared to be stronger amongwomen who were of normal weightbefore pregnancy.

The results of our study are generallyconsistent with previous studies of excessgestational weight gain and subsequentchildhood overweight/obesity. A 2012meta-analysis concluded that excessgestational weight gain results in at leasta 21% increase in risk of childhoodobesity.21 Greater gestational weight gain(based on the 1990 IOM recommenda-tions) has also been associated withhaving offspring with a higher systolicblood pressure and a risk of overweightas well as increased adiposity at 3 years of


age, as measured by skinfold thicknessand BMI z-score.9 Results from anotherstudy found that the children of motherswho gained excess weight during preg-nancy (per the 2009 IOM recommen-dations) had 48% greater odds ofoverweight at 7 years of age than thechildren of mothers who met therecommendations.22

Research evaluating the relationshipbetween low gestational weight gain andchildhood overweight/obesity has pro-duced mixed conclusions. Hinkle et al23

found no association between low gesta-tional weight gain and BMI z-score at5 years of age in any prepregnancy BMIgroup, whereas Ehrenthal et al24 foundthat low gestational weight gain wassignificantly related to BMI z-score at 4years of age.A recent review article found several

studies that reported a U- or J-shapedassociation between gestational weightgain and child adiposity, in which thelowest maternal gains showed greaterrisk of childhood overweight.25 The au-thors speculated that this may occurbecause of a survival phenotype in whichinfants with poor in utero nutrition ex-perience accelerated weight gain early inlife known as catch-up growth. Althoughthis provides benefits for early life sur-vival, it can have an adverse impact onoutcomes in adolescence and child-hood, such as obesity and metabolic

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disorders.25 Evidence from the Dutchfamine of 1944-1945 supports this hy-pothesis.26 Our findings that low gesta-tional weight gain, especially amongnormal-weight women, was associatedwith increased odds of subsequentchildhood overweight/obesity, areintriguing and represent an avenue forfuture studies to explore.

It is well established that parentalobesity is a strong risk factor for child-hood obesity, especially between the agesof 3 and 5 years.27 One study founda significant association between excessgestational weight gain and child BMIz-score only among mothers who werenot obese (prepregnancy BMI <30 kg/m2),23 whereas a retrospective cohortstudy found that the impact of excessgestational weight gain was strongestamong women who were underweightbefore pregnancy.22,23

This lends support to the hypoth-esis that the impact of gestational weightgain on childhood overweight/obesitymay be stronger among normal-weightwomen whose child is not already atincreased risk because of genetic predis-position28 or familial behavioral factors;for example, the child of an overweightor obese woman might share similarlifestyle habits or behaviors. Early child-hood is a time when children internalizephysical activity and eating behaviorsdemonstrated by their parentalmodels.29,30

It is hypothesized that excessive ma-ternal body weight alone or gestationalweight gain can both produce permanentchanges in the fetal biological systemsthat regulate body weight.8 Weight gain isinversely related to insulin sensitivity, andobese women enter pregnancy highlyinsulin resistant; therefore, their de-creases in insulin sensitivity are smaller,resulting in less gestational weight gainthan normal-weight women.31 At thestart of pregnancy, the fetus of an obesewoman is already at risk for excessivenutrient intake because of the highinsulin resistance in the mother. Bycontrast, excess gestational weight gainin normal-weight women (who have in-creased pregravid insulin sensitivity)could generate greater decreases in insu-lin sensitivity, resulting in excess nutrient

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intake and increased adiposity in thefetus.

In addition to prepregnancy BMI,metabolic changes that influence gesta-tional weight gain may indirectly in-fluence fetal growth and potentiallychildhood weight because the offspringof obese women may be predisposed tooverconsume energy and lead a moresedentary lifestyle. Rapid growth in in-fancy has been associated with obesitylater in life in multiple studies.32

A limitation of this study is that welacked information on breast-feedingpractices or the child’s diet after birth.However, we were able to control formaternal nutrition before pregnancy,which likely is related to diet duringpregnancy and the child’s dietary habits.One strength of this study is that themajority of the sample had measuredprepregnancy weights. The remainingweights were self-reported, which mayhave underestimated actual weight;however, this was only a small propor-tion of the sample (10%), and we andother investigators have observed thatself-reported prepregnancy weight ap-proximates the true value.33,34 Further-more, a sensitivity analysis excludingthose with self-reported weights foundno difference. This study is among theearliest to evaluate this relationship us-ing the new 2009 IOM recommenda-tions, which were updated to account fornew research on pregnancy outcomes aswell as increases in BMI and otherchanges in the child-bearing population.Our large cohort was also very raciallydiverse, making the results more gener-alizable and allowing us adequate powerto assess effect modification by pre-pregnancy BMI.

Maternal gestational weight gainboth below and above the IOM rec-ommendations was associated with anincreased risk of subsequent childhoodoverweight/obesity in young children(aged 2-5 years), especially amongnormal-weight women. Future direc-tions include developing lifestyle in-terventions that help women achieveappropriate weight gain during preg-nancy and conducting clinical trials toevaluate the effectiveness of such in-terventions in achieving adequate

gestational weight gain and reducingchildhood obesity. -

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