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besity rates in our society are at an all-time high,proportionately affecting reproductive-age women.Obesity in pregnancy is associated with a high fre-

uency of adverse pregnancy outcomes, having both peri-atal and long-term implications for mother and her off-pring (1). The impact of obesity in pregnancy onffspring risk of obesity requires further research. More-ver, nutrition guidance regarding appropriate preg-ancy weight gain has not evolved to address the obesitypidemic (2).Obese mothers are more likely to have obese children

3). Childhood obesity is a major public health problemssociated with significant comorbidities and is notori-usly difficult to reverse. Specifically, the rate of obesityn middle-class preschool-age children has dramaticallyncreased during the past 22 years (4), and recent longi-udinal studies indicate that once children that age arebese, the risk of remaining obese in adulthood is dou-led (5). Accordingly, researchers have theorized thatntervention to prevent obesity must occur early in life6,7). Such intervention requires identifying infants atisk for obesity before these children become over-eight.Factors present in the fetal-neonatal period that have

een correlated to later obesity risk include: large birtheight, maternal diabetes mellitus (including gestationaliabetes mellitus), excessive gestational weight gain, ma-ernal smoking, and obesity in pregnancy (3,8-11). Re-ently, much research has focused on the long-term ef-ects that the perinatal environment has on theeveloping fetus, termed metabolic programming. Theevelopmental origins of health and disease hypothesizeshat metabolic programming in utero can have a lifelongmpact on offspring (12). Gluckman and Hanson expandhis hypothesis to epigenetic mechanisms that may altern individual’s risk of obesity (13). Further understand-

. Josefson is an assistant professor, Feinberg School ofedicine, Northwestern University Department of Pedi-

trics, Division of Endocrinology, Children’s Memorialospital, Chicago, IL.Address correspondence to Jami Josefson, MD, Feinberg

chool of Medicine, Northwestern University, Departmentf Pediatrics, Division of Endocrinology, Children’s Memo-ial Hospital, 2300 Children’s Plaza, MC 54, Chicago IL0614. E-mail: J-Josefson@northwestern.eduManuscript accepted: September 29, 2010.Copyright © 2011 by the American Dietetic

ssociation.0002-8223/$36.00

odoi: 10.1016/j.jada.2010.10.015

0 Journal of the AMERICAN DIETETIC ASSOCIATION

ng of the intrauterine environment among obese womennd its relative contribution to risk of offspring obesityill give insight into the mechanisms underlying its

ause.

ATERNAL OBESITYaternal prepregnancy body mass index (BMI) in the

verweight/obese range is one of the most important riskactors for childhood obesity (3,14). Maternal obesity islearly linked to obesity in offspring (15), and may helpdentify infants at risk of developing obesity. Yet, the

echanism causing this correlation is not fully under-tood (16). Risk of obesity is highly familial (17); there-ore, genetics play a role. However, the dramatic increasef obesity prevalence over the span of 30 years indicatesdditional factors are involved (7). Moreover, Kral andolleagues demonstrated that offspring born to formerlybese women who lost substantial weight after gastricypass surgery exhibited significantly reduced rates ofbesity compared with older siblings born before theirother’s weight loss (18).Obese women have higher rates of gestational diabetesellitus compared with healthy-weight women. Several

esearch studies, including a long-term study conductedt the Northwestern University Diabetes in Pregnancyenter, have shown that offspring of women with gesta-

ional diabetes mellitus are more likely to become obeseuring childhood (9,10). Although adverse outcomes as-ociated with diabetes in pregnancy have been well-char-cterized, outcomes associated with obesity in pregnancyithout diabetes have not been well-studied. Given thatlmost 40% of women of reproductive age in the Unitedtates are overweight or obese (19) and approximately% of pregnant women have gestational diabetes mellitus20), further understanding of the obese intrauterine en-ironment without diabetes is warranted.Obese pregnant women may have impaired glucose

olerance and insulin resistance, even if they do not meetriteria for the diagnosis of diabetes in pregnancy. Thus,heir infants may display some features of infants ofiabetic mothers, such as increased body fat at birth21,22).

Lipid and inflammatory pathways are known to alteretabolism during pregnancy, thereby creating meta-

olic programming toward fat deposition in the fetus (23).odent models of maternal overnutrition display off-pring with increased fat mass and higher levels of glu-ose, insulin, leptin, and triglycerides (24). These studiesndicate multiple maternal factors contribute to offspring

besity risk.

© 2011 by the American Dietetic Association

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XCESSIVE GESTATIONAL WEIGHT GAINn addition to prepregnancy obesity, excessive weightain during pregnancy is strongly associated with mater-al and fetal complications (1). Women who gain exces-ive weight during pregnancy (more than 46 lb) have auch higher risk of having a macrosomic neonate (de-ned as weighing more than 4,500 g) (25). Guidelines forregnancy weight gain were developed by the Institutef Medicine in 1990 to reduce the risk of low-birth-weightnfants (26). The increased weight recommendationsave not reduced the risk of low-birth-weight infants,owever, and may no longer be appropriate given the

ncreasing prevalence of obesity among reproductive-ageomen (2). Recently these guidelines were revised to

arget obese pregnant women with the recommendationhat obese women limit gestational weight gain to 11 to0 pounds (Table) (27-30). Further gestational weightain recommendations were not provided for differentbesity classes (Class 1: BMI�30-34.9, class 2: BMI�5-39.9, class 3: BMI�40) (31). Prepregnancy BMI isssociated with increased risk of perinatal and deliveryomplications on a continuum (1). Therefore, a singletandard of weight gain for all obese women is notppropriate.Short-term and long-term studies have documented

hat the offspring of women whose weight gain duringregnancy exceeded the guidelines are more likely toecome overweight (11,32). These studies showed pos-tive linear associations between gestational weightain and childhood BMI. Recent findings from theouthampton’s Women’s Survey, a prospective cohortf pregnant women and their offspring, showed thatomen who gained excessive gestational weight (de-ned by the Institute of Medicine 2009 guidelines) hadffspring with greater fat mass in the newborn per-od and at 6 years of age (33). This study used dual-ray absorptiometry to measure neonatal and child-ood adiposity. More studies are needed to gauge the

mpact of gestational weight gain on offspring body

Table. 2009 Institute of Medicine Guidelines: Weight gain duringpregnancy

PrepregnancyBMIa BMIa

Totalweightgainrange (lb)

Rates of weight gainb

in 2nd and 3rdtrimester (meanrange in lb/wk)

Underweight �18.5 28-40 1 (1-1.3)Normal weight 18.5-24.9 25-35 1 (0.8-1)Overweight 25.0-29.9 15-25 0.6 (0.5-0.7)Obese

(includes allclasses) �30.0 11-20 0.5 (0.4-0.6)

aBMI�body mass index, calculated as kg/m2.bCalculations assume a 0.5 to 2 kg (1.1 to 4.4 lb) weight gain in the first trimester(based on Siega-Riz and colleagues 1994 [28]; Abrams and colleagues, 1995 [29];Carmichael and colleagues, 1997[30]).

omposition. fi

IRTH WEIGHT AND NEONATAL BODY COMPOSITIONumerous studies have examined birth weight as it re-

ates to obesity risk: babies born large at birth are moreikely to become obese (8), but most obese children had aormal birth weight (7). Noting that inconsistency, Okennd Gillman suggest in a review article that factorsresent at birth, other than birth weight, particularlyncreased adiposity, may convey increased risk of obesity8). In the long-term follow-up gestational diabetes mel-itus studies, higher obesity rates in offspring werehought to be due to higher fetal insulin levels (34). Sub-equent studies concluded that at birth newborns of ges-ational diabetes mellitus mothers have more adiposity35) and higher insulin levels (36), which persisted intodolescence (10). These studies indicate that large birtheight is neither necessary nor sufficient to predict later

besity, but that newborn adiposity is a potential indica-or of obesity risk (9,10).

Body fat at birth may represent the intrauterine nutri-ional environment whereby overnutrition (obesity or ex-essive pregnancy weight gain) leads to increased new-orn adiposity. This has been demonstrated by theyperglycemia and Adverse Pregnancy Outcomes study,

n which increased neonatal adiposity (measured in9,000 newborns) occurred on a continuum of maternallucose levels (22) less than the diagnostic cutoff for ges-ational diabetes mellitus. In a smaller study, newbornsorn to overweight/obese women without diabetes hadignificantly higher percentage body fat compared withewborns of average-weight women (11.6% vs 9.7%) (21).hese studies measured newborn body fat with calipers,method with limited accuracy and reliability. Few stud-

es (33) have quantified newborn body fat measurementsecause of the challenge in obtaining accurate data.ewer technologies, such as the method of air displace-ent plethysmography, dual x-ray absorptiometry scan-

ing, and magnetic resonance imaging of abdominal ad-pose tissue may help overcome this challenge.

ONCLUSIONrevention of obesity in pregnancy is ideally achieved byaving obese women lose weight prior to conception.verweight and obese women would benefit from lifestyle

hanges, including exercise and weight loss prior to preg-ancy. However, achieving a healthy BMI before preg-ancy for all women is not a realistic goal. Therefore,verweight and obese women should receive behaviorodification counseling early in their pregnancy. Preg-

ancy is an ideal time to encourage behavioral changesecause pregnant women have frequent contact withealth care providers and often their motivation level toave a positive pregnancy outcome is high.All pregnant women should be provided with guide-

ines on an appropriate rate of weight gain based on theirrepregnancy BMI. Obese women, especially those with aMI more than 35, need more individualized gestationaleight gain recommendations. In addition, women

hould be encouraged to eat a healthy low-fat diet duringheir pregnancy, improving their consumption of fruits,egetables, and fiber. Through public health campaigns,regnant women seem to be familiar with the need tovoid certain harmful foods and behaviors (alcohol, raw

sh and meats, cigarette smoking). However, a greater

January 2011 ● Journal of the AMERICAN DIETETIC ASSOCIATION 51

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mphasis is needed on increasing consumption of nutri-nt-rich foods during pregnancy.In summary, further research is needed to determine

he impact of the obese intrauterine environment andxcessive pregnancy weight gain on offspring risk of obe-ity. Characterizing the anthropometric and metabolictatus of offspring of obese women will lead to furthernderstanding of the relative contribution of metabolicrogramming to offspring obesity risk. That understand-ng, in turn, will facilitate intervention during pregnancyo mitigate risk of offspring obesity, thereby reversing thebesity epidemic.

TATEMENT OF POTENTIAL CONFLICT OF INTEREST:o potential conflict of interest was reported by theuthor.FUNDING/SUPPORT: The author received no funding

o write this commentary/editorial.

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