Increasing prepregnancy body mass index: analysis of trends and contributing variables

Altered DNA methylation and Dnmt expression in obese uterus may cause implantation failure

Obesity is defined by increased adipose tissue volume and has become a major risk factor for reproduction. Recent studies have revealed a substantial link between obesity and epigenetics. The epigenome is dynamically regulated mainly by DNA methylation. DNA methylation, which is controlled by DNA methyltransferases (Dnmts), has been widely studied because it is essential for imprinting and regulation of gene expression. In our previous study, we showed that the levels of Dnmt1, Dnmt3a and global DNA methylation was dramatically altered in the testis and ovary of high-fat diet (HFD)-induced obese mice. However, the effect of HFD on Dnmts and global DNA methylation in mouse uterus has not yet been demonstrated. Therefore, in the present study, we aimed to evaluate the effect of HFD on the level of Dnmt1, Dnmt3a, Dnmt3b, Dnmt3l and global DNA methylation in uterus. Our results showed that HFD significantly altered the levels of Dnmts and global DNA methylation in the uterus. The total expression of Dnmt1, Dnmt3a and Dnmt3b was significantly upregulated, while level of Dnmt3l and global DNA methylation were dramatically decreased (p < 0.05). Furthermore, we observed that the expression of Dnmt3b and Dnmt3l was significantly increased in endometrium including gland and epithelium (p < 0.05). Although Dnmt3b was the only protein whose expression significantly increased, the level of global DNA methylation and Dnmt3l significantly decreased in stroma and myometrium (p < 0.05). In conclusion, our results show for the first time that obesity dramatically alters global DNA methylation and expression of Dnmts, and decreased DNA methylation and Dnmt expression may cause abnormal gene expression, especially in the endometrium.

Weight gain during pregnancy: A narrative review on the recent evidences

Gestational weight gain is necessary for the normal fetus development, in fact a series of studies have evidenced that both low and excessive gestational weight gain is associated with negative fetal-neonatal outcomes. So, evidences on the optimal gestational weight gain across the ranges of the pre-pregnancy maternal body mass index are necessary. In this context, while for normal weight and underweight the recommendations of IOM are clearly stated and supported by well designed and conducted clinical studies, those for the obese pregnant women are even today debated. Pre-pregnancy obesity is associated with high risk to develop hypertension, gestational diabetes, cesarean section and high birth weight. The Institute of Medicine guidelines, in 2009, recommended that women with obesity gain 11-20 lb at a rate of 0.5 lb/week during the second and third trimesters of pregnancy. Successively, taking into account a series of meta-analysis, the American College of Obstetricians and Gynecologists emphasized that the IOM weight gain targets for obese pregnant women are too high. However the high risk to have babies small for gestational age, related to a low weight gain or a losing of weight during pregnancy, has also been demonstrated. More recent studies have taken into consideration the maternal and fetal outcomes of obese pregnant women with different obesity class (I,II,III) and different weight gain during pregnancy. The analysis of these studies, discussed in this narrative review, show that the appropriate gestational weight gain should be personalized considering the three obesity class; furthermore both an upper and lower limit of gestational weight gain should be reconsidered in order to prevent the negative maternal and fetal outcomes in these women.

Effects of central obesity on maternal complications in Korean women of reproductive age

BACKGROUND

Considering the obesity-related complications in pregnancy and during delivery, prepregnancy central obesity may also affect pregnancy-related complications. This study aimed to assess the relationship between prepregnancy central obesity and adverse maternal outcomes in Korean women, by using the Korean National Health Insurance Service (NHIS) cohort.

METHODS

In this population-based retrospective cohort study, we used data from the NHIS database, which contains information of health-care utilisation, diagnosis and prescription, and mortality for almost the whole Korean population, together with data from the NHIS health checkup database from 2005 to 2015. The NHIS health checkup data (645-280 days before childbirth) of mothers who had deliveries (total, 783,406 deliveries) from 2006 to 2015 were collected. For maternal adverse outcome data, we searched for diagnoses of maternal complications made during the period of 280 days before each delivery. The odds for maternal complications according to 8 body mass index (BMI) and 10 waist circumference (WC) categories were analysed using logistic regression.

RESULTS

The incidence rates of eclampsia/preeclampsia, caesarean section, multiple gestation, and polycystic ovary syndrome (PCOS) increased according to the increase of BMI and WC. In contrast, the incidence rate of premature rupture of membrane (PROM) was inversely correlated with BMI and WC. In the low BMI (<17.5 and 17.5-19.9 kg/m2) and low WC (<60 and 60.0-64.0 cm) groups, the odds of threatened abortion were elevated.

CONCLUSION

Prepregnancy WC was closely linked to some maternal complications, including eclampsia/preeclampsia, cesarean section, PCOS, and PROM, in a manner similar to prepregnancy BMI.

Maternal overnutrition programs epigenetic changes in the regulatory regions of hypothalamic Pomc in the offspring of rats

Background and objective

Maternal overnutrition has been implicated in affecting the offspring by programming metabolic disorders such as obesity and diabetes, by mechanisms that are not clearly understood. This study aimed to determine the long-term impact of maternal high-fat (HF) diet feeding on epigenetic changes in the offspring’s hypothalamic Pomc gene, coding a key factor in the control of energy balance. Further, it aimed to study the additional effects of postnatal overnutrition on epigenetic programming by maternal nutrition.

Methods

Eight-week-old female Sprague–Dawley rats were fed HF diet or low-fat (LF) diet for 6 weeks before mating, and throughout gestation and lactation. At postnatal day 21, samples were collected from a third offspring and the remainder were weaned onto LF diet for 5 weeks, after which they were either fed LF or HF diet for 12 weeks, resulting in four groups of offspring differing by their maternal and postweaning diet.

Results

With maternal HF diet, offspring at weaning had rapid early weight gain, increased adiposity, and hyperleptinemia. The programmed adult offspring, subsequently fed LF diet, retained the increased body weight. Maternal HF diet combined with offspring HF diet caused more pronounced hyperphagia, fat mass, and insulin resistance. The ARC Pomc gene from programmed offspring at weaning showed hypermethylation in the enhancer (nPE1 and nPE2) regions and in the promoter sequence mediating leptin effects. Interestingly, hypermethylation at the Pomc promoter but not at the enhancer region persisted long term into adulthood in the programmed offspring. However, there were no additive effects on methylation levels in the regulatory regions of Pomc in programmed offspring fed a HF diet.

Conclusion

Maternal overnutrition programs long-term epigenetic alterations in the offspring’s hypothalamic Pomc promoter. This predisposes the offspring to metabolic disorders later in life.

Secular Trends on Birth Parameters, Growth, and Pubertal Timing in Girls with Turner Syndrome

BACKGROUND

Whether children with chromosomal disorders of growth and puberty are affected by secular trends (STs) as observed in the general population remains unanswered, but this question has relevance for expectations of spontaneous development and treatment responses.

OBJECTIVES

The aim of the study was to evaluate STs in birth parameters, growth, and pubertal development in girls with Turner syndrome (TS).

STUDY DESIGN

Retrospective analysis of KIGS data (Pfizer International Growth Database). We included all TS patients who entered KIGS between 1987 and 2012 and were born from 1975 to 2004, who were prepubertal and growth treatment naïve at first entry (total number: 7,219). Pretreatment height and ages at the start of treatment were compared across 5-year birth year groups, with subgroup analyses stratified by induced or spontaneous puberty start.

RESULTS

We observed significant STs across the birth year groups for birth weight [+0.18 SD score (SDS), p < 0.001], pretreatment height at mean age 8 years (+0.73 SDS, p < 0.001), height at the start of growth hormone (GH) therapy (+0.38 SDS, p < 0.001) and start of puberty (+0.42 SDS, p < 0.001). Spontaneous puberty onset increased from 15 to 30% (p < 0.001). Mean age at the start of GH treatment decreased from 10.8 to 7.4 years (-3.4 years; p < 0.001), and substantial declines were seen in ages at onset of spontaneous and induced puberty (-2.0 years; p < 0.001) and menarche (-2.1 years; p < 0.001).

CONCLUSION

Environmental changes leading to increased height and earlier and also more common, spontaneous puberty are applicable in TS as in normal girls. In addition, greater awareness for TS may underlie trends to earlier start of GH therapy and induction of puberty at a more physiological age.

Body Mass Index, Weight Gain, and Hypertensive Disorders in Pregnancy

BACKGROUND

This study examines the interrelationship between gestational weight gain, pre-pregnancy body mass index (BMI), race/ethnicity, and their association with hypertensive disorders during pregnancy (HDP).

METHODS

Data from the 2004-2011 national Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed. Women with singleton live births were included in the analysis (N = 270,131). Gestational weight gain was categorized reflecting the Institute of Medicine (IOM) weight gain recommendation (no gain/weight loss; ≤11, 12-14; 15-25; 26-35; ≥36 pounds). Pre-pregnancy BMI (underweight; normal; overweight; obese) and race/ethnicity (non-Hispanic (NH) White, NH-Black, Hispanic, and NH-other) were examined. Hypertensive disorders during pregnancy were dichotomized (HDP; no HDP). Data were stratified by BMI and race/ethnicity, and multiple logistic regression analysis was conducted to generate odds ratios and 95% confidence intervals (CIs).

RESULTS

Compared to normal and overweight women who gained the IOM recommended weight, higher odds of HDP was observed in those who gained ≥36 pounds regardless of their race/ethnicity. Among obese NH-White (odds ratio (OR) = 1.29, 95% CI = 1.11, 1.50) and Hispanic women (OR = 1.64, 95% CI = 1.05, 2.54), the odds of HDP was higher among those who gained 25-35 pounds and those who gained ≥36 pounds (OR = 1.59, 95% CI = 1.37, 1.85) and (OR = 2.20, 95% CI = 1.41, 3.44), respectively. However, for NH-Black obese women, higher odds of HDP was observed among those who gained ≥36 pounds (OR = 1.34, 95% CI = 1.04, 1.73).

CONCLUSIONS

Although there are some ethnic/racial variations, pregnant women who exceeded gestational weight gain recommendations are at increased risk of HDP. Health care providers should consider the interrelationship between pre-pregnancy gestational weight gain (GWG) and BMI when counseling patients regarding HDP.

Maternal High-fat Diet Accelerates Development of Crohn's Disease-like Ileitis in TNFΔARE/WT Offspring

BACKGROUND

Maternal high-fat diet (HFD) and obesity increases the risk of the offspring to develop inflammatory processes in various organs including the gut. We hypothesized that maternal diet-induced obesity programs the fetal gut towards inflammation in a mouse model of genetically-driven Crohn's disease (CD)-like ileitis.

METHODS

TNF(WT/WT) and TNF(ΔARE/WT) dams were fed an experimental control diet (CTRLD; 13 kJ% fat) or HFD (48 kJ%). Offspring mice were fed CTRLD or HFD at 4 weeks of age. Metabolic characteristics and severity of CD-like ileitis was assessed in 8- and 12-week old WT and ARE offspring measuring tissue histopathology and markers of inflammation in the distal ileum as well as plasma cytokine and LPS levels. To study prenatal effects, we laser microdissected fetal intestinal epithelial cells at 17.5 days postconception and performed microarray-based global gene expression analysis.

RESULTS

Maternal HFD significantly accelerated the severity of CD-like ileitis in HFD-fed ARE mice at early life stages associated with increased mucosal neutrophil infiltration, Il12p40 expression, and portal vein LPS levels. In contrast to WT mice, metabolic characteristics of ARE offspring were not affected by maternal HFD. Gene expression patterns in fetal intestinal epithelial cells of ARE mice remained largely unchanged under conditions of maternal diet-induced obesity suggesting that the positive association of intestinal inflammation, portal vein endotoxemia, and plasma TNF levels is independent of prenatal conditioning of the gut epithelium.

CONCLUSIONS

Maternal HFD promotes the early onset of severe CD-like ileitis in genetically susceptible offspring independent of metabolic alterations.

Promoting weight loss methods in parenting magazines: Implications for women

Weight gain before and after pregnancy is important for women's health. The purpose of this study was to assess articles and advertisements related to weight loss in three widely read parenting magazines, "Parenting School Years," "Parenting Early Years," and "Parenting," which have an estimated combined readership of approximately 24 million (mainly women readers). Almost a quarter (23.7%, n = 32) of the 135 magazine issues over a four year period included at least one feature article on weight loss. A variety of topics were covered in the featured articles, with the most frequent topics being on losing weight to please yourself (25.2%), healthy ways to lose weight (21.1%), and how to keep the weight off (14.7%). Less than half (45.9%) of the articles displayed author credentials, such as their degree, qualifications, or expertise. A fifth (20.0%, n = 27) of the magazines included at least one prominent advertisement for weight loss products. Almost half (46.9%) of the weight loss advertisements were for weight loss programs followed by weight loss food products (25.0%), weight loss aids (21.9%), and only 6.2% of the advertisements for weight loss were on fitness. Parenting magazines should advocate for healthy weight loss, including lifestyle changes for sustained health.

An evaluation of the implementation of maternal obesity pathways of care: a mixed methods study with data integration

OBJECTIVES

Maternal obesity has multiple associated risks and requires substantial intervention. This research evaluated the implementation of maternal obesity care pathways from multiple stakeholder perspectives.

STUDY DESIGN

A simultaneous mixed methods model with data integration was used. Three component studies were given equal priority. 1: Semi-structured qualitative interviews explored obese pregnant women's experiences of being on the pathways. 2: A quantitative and qualitative postal survey explored healthcare professionals' experiences of delivering the pathways. 3: A case note audit quantitatively assessed pathway compliance. Data were integrated using following a thread and convergence coding matrix methods to search for agreement and disagreement between studies.

RESULTS

Study 1: Four themes were identified: women's overall (positive and negative) views of the pathways; knowledge and understanding of the pathways; views on clinical and weight management advice and support; and views on the information leaflet. Key results included positive views of receiving additional clinical care, negative experiences of risk communication, and weight management support was considered a priority. Study 2: Healthcare professionals felt the pathways were worthwhile, facilitated good practice, and increased confidence. Training was consistently identified as being required. Healthcare professionals predominantly focussed on women's response to sensitive obesity communication. Study 3: There was good compliance with antenatal clinical interventions. However, there was poor compliance with public health and postnatal interventions. There were some strong areas of agreement between component studies which can inform future development of the pathways. However, disagreement between studies included a lack of shared priorities between healthcare professionals and women, different perspectives on communication issues, and different perspectives on women's prioritisation of weight management.

CONCLUSION

The differences between healthcare professionals' and women's priorities and perspectives are important factors to consider when developing care pathways. Shared perspectives could help facilitate more effective implementation of the pathway interventions that have poor compliance.

Multiple micronutrient needs in pregnancy in industrialized countries

BACKGROUND

As nutritional deficiencies are known to lead to adverse pregnancy outcomes, a woman's nutritional status should be assessed preconceptionally with the goal of optimizing maternal, fetal and infant health. Worldwide micronutrient intakes do not fit pregnancy requirements, so that their supplementation is recommended from the beginning of pregnancy in most of the low- and middle-income countries. Conversely, data on multiple supplementation in developed countries appear few and controversial. Key Message: Although a balanced diet is generally accessible in industrialized countries, a switch to a high-fat and low-quality diet has led to an inadequate vitamin and mineral intake during pregnancy, so that recent data show the micronutrient intake and supplementation to be lower than recommended even in high-income countries, particularly for iron, folic acid, calcium and vitamin D.

CONCLUSIONS

Currently, even if there is insufficient evidence to support routine supplementation at the population level, except for periconceptional folate supplementation, these results need to be evaluated at an individual level in order to avoid nutritional deficiencies and to encourage women to establish healthful dietary practices prior to conception. The new goal in industrialized countries needs to be an individualized approach that takes account of the phenotypic, genotypic and metabolic differences among individuals of the same population.

Maternal obesity, gestational weight gain, and offspring adiposity: the exploring perinatal outcomes among children study

OBJECTIVE

To determine whether adequate vs excessive gestational weight gain (GWG) attenuated the association between maternal obesity and offspring outcomes.

STUDY DESIGN

Data from 313 mother-child pairs participating in the Exploring Perinatal Outcomes among Children study were used to test this hypothesis. Maternal prepregnancy body mass index (BMI) and weight measures throughout pregnancy were abstracted from electronic medical records. GWG was categorized according to the 2009 Institute of Medicine criteria as adequate or excessive. Offspring outcomes were obtained at a research visit (average age 10.4 years) and included BMI, waist circumference (WC), subcutaneous adipose tissue (SAT) and visceral adipose tissue, high-density lipoprotein cholesterol, and triglyceride levels.

RESULTS

More overweight/obese mothers exceeded the Institute of Medicine GWG recommendations (68%) compared with normal-weight women (50%) (P < .01). Maternal prepregnancy BMI was associated with worse childhood outcomes, particularly among offspring of mothers with excessive GWG (increased BMI [20.34 vs 17.80 kg/m(2)], WC [69.23 vs 62.83 cm], SAT [149.30 vs 90.47 cm(2)], visceral adipose tissue [24.11 vs 17.55 cm(2)], and homeostatic model assessment [52.52 vs 36.69], all P < .001). The effect of maternal prepregnancy BMI on several childhood outcomes was attenuated for offspring of mothers with adequate vs excessive GWG (P < .05 for the interaction between maternal BMI and GWG status on childhood BMI, WC, SAT, and high-density lipoprotein cholesterol).

CONCLUSION

Our findings lend support for pregnancy interventions aiming at controlling GWG to prevent childhood obesity.

Maternal health issues and cardio-metabolic outcomes in the offspring: a focus on Indigenous populations

Non-communicable diseases (NCDs) including diabetes, obesity and cardiovascular disease are the leading causes of death worldwide. Indigenous populations are disproportionally affected. In an effort to halt the increasing disease burden, the mechanisms underlying the increasing rate of NCDs are an important area of study. Recent evidence has focused on the perinatal period as an influential period impacting the future cardio-metabolic health of the offspring. This concept has been defined as metabolic foetal programming and supports the importance of the developmental origins of health and disease in research and clinical practice, specifically in prevention efforts to protect future generations from NCDs. An understanding of the underlying mechanisms involved is not clear as of yet. However, an understanding of these mechanisms is imperative in order to plan effective intervention strategies. As much of the discussion below is gleaned from large epidemiological studies and animal studies, further research with prospective cohorts is necessary.

Potential for a stress reduction intervention to promote healthy gestational weight gain: focus groups with low-income pregnant women

BACKGROUND

Prepregnancy body mass index and excessive gestational weight gain (GWG) are associated with adverse maternal and infant outcomes. Because stress contributes to obesity and eating behaviors, stress reduction interventions during pregnancy may be a novel way to influence GWG, positively affect maternal and infant outcomes, and address the obesity epidemic intergenerationally.

METHODS

Our research team is developing a mindfulness-based stress reduction and nutrition intervention for low-income, overweight and obese pregnant women, with healthy GWG as the primary outcome measure. To inform development of the intervention, we conducted focus groups with our target population. Focus group transcripts were analyzed for themes related to sources and importance of stress, relationship between stress and eating, and motivation for a stress reduction pregnancy intervention.

FINDINGS

Fifty-nine low-income pregnant women from the San Francisco Bay Area participated in focus groups and completed a questionnaire. The vast majority of women (80%) reported experiencing significant stress from a variety of sources and most recognized a relationship between stress and eating in their lives.

CONCLUSIONS

This at-risk population seems to be extremely interested in a stress reduction intervention to support healthy GWG during pregnancy. The women in our groups described high levels of stress and a desire for programs beyond basic dietary recommendations. These findings inform practitioners and policymakers interested in pregnancy as a "window of opportunity" for behavior change that can affect the metabolic and weight trajectory both for women and their offspring.

Increased maternal BMI is associated with infant wheezing in early life: a prospective cohort study

Rates of obesity are increasing in women of child bearing age with negative impacts on maternal and offspring health. Emerging evidence suggests in utero origins of respiratory health in offspring of obese mothers but mechanisms are unknown. Changes in maternal cortisol levels are one potential factor as cortisol levels are altered in obesity and cortisol is separately implicated in development of offspring wheeze. We aimed to assess whether increased pre-pregnancy maternal body mass index (BMI) was associated with offspring early life wheezing, and whether this was mediated by altered cortisol levels in the mother. In a prospective community-based cohort (Amsterdam Born Children and their Development cohort), women completed questionnaires during pregnancy and at 3-5 months post-delivery regarding self-history of asthma and atopy, and of wheezing of their offspring (n=4860). Pre-pregnancy BMI was recorded and serum total cortisol levels were measured in a subset of women (n=2227) at their first antenatal visit. A total of 20.2% (n=984) women were overweight or obese and 10.3% reported wheezing in their offspring. Maternal BMI was associated with offspring wheezing (1 unit (kg/m2) increase, OR: 1.03; 95% CI: 1.00-1.05), after correction for confounders. Although maternal cortisol levels were lower in overweight mothers and those with a history of asthma, maternal cortisol levels did not mediate the increased offspring wheezing. Pre-pregnancy BMI impacts on baby wheezing, which is not mediated by lower cortisol levels. As the prevalence of obesity in women of child-bearing age is increasing, further studies are needed to investigate modifiable maternal factors to avoid risk of wheezing in young children.

Obesity in pregnancy: addressing risks to improve outcomes

The rapidly increasing rates of obesity among women of childbearing age, not only in the United States but also across the globe, contribute to increased risks during pregnancy and childbirth. Overweight and obesity are quantified by body mass index (BMI) for clinical purposes. In 2010, 31.9% of U.S. women aged 20 to 39 years met the definition of obesity, a BMI of 30 kg/m or greater. Across the life span, obesity is associated with increased risks of hypertension, cardiovascular disease, diabetes, sleep apnea, and other diseases. During pregnancy, increasing levels of prepregnancy BMI are associated with increases in both maternal and fetal/neonatal risks. This article reviews current knowledge about obesity in pregnancy and health risks related to increased maternal BMI, addresses weight stigma as a barrier to care and interventions that have evidence of benefit, and discusses the development of policies and guidelines to improve care.

Effects of a weight-gain restriction programme for obese pregnant women on sickness absence and pregnancy benefits

OBJECTIVE

To evaluate the effect of a weight-gain restriction programme for obese pregnant women on sickness absence days and pregnancy benefit days during pregnancy and postpartum.

DESIGN

A prospective, controlled intervention study. The Swedish Social Security Agency's records were utilized to compile sickness absence and pregnancy benefit information.

SETTING

Antenatal care clinics in the south-east of Sweden.

SUBJECTS

One hundred fifty-five obese pregnant women who participated in a weight restriction program with weekly structured motivational and behavioural talks combined with aqua-aerobics during pregnancy. A total of 193 obese pregnant women with no intervention served as controls.

MAIN OUTCOME MEASURES

Sickness absence benefits and pregnancy benefits expressed as a percentage.

RESULTS

On average women in the intervention group had 76.68 total full days of sickness absence benefit compared with 53.09 days in the control group. Total full days of pregnancy benefits were 39.66% days and 41.41% for the intervention and control groups respectively. For the women who were on sick leave there were no differences between the groups in the amount of days taken.

CONCLUSIONS

Given the complexity of factors that have an influence on sickness absence leave, it is possible that programmes that do not address the influence of social aspects and attitudes towards sickness absence have limited effect.

Limiting excess weight gain in healthy pregnant women: importance of energy intakes, physical activity, and adherence to gestational weight gain guidelines

Few studies have investigated if compliance with energy intakes, physical activity, and weight gain guidelines attenuate postpartum weight retention (PPWR) in mothers attending prenatal classes. We investigated whether (a) daily energy intakes within 300 kcal of estimated energy requirements (EERs), (b) walking more than 5000 steps/day, (c) targeting the recommended weight gain goals for prepregnancy BMI, and/or (d) achieving weekly or total gestational weight gain (GWG) recommendations minimized PPWR in 54 women attending prenatal classes in Montreal/Ottawa, Canada. Participants completed a validated pregnancy physical activity questionnaire (PPAQ), 3 telephone-validated 24-hr dietary recalls, and wore a pedometer for one week. PPWR was measured 6 weeks after delivery. Results showed that 72% had healthy prepregnancy BMIs. However, 52% consumed >300 kcal/day in excess of their EER, 54% exceeded recommended GWG, and more overweight (93%) than normal weight women (38%) cited nonrecommended GWG targets. Following delivery, 33% were classified as overweight, and 17% were obese. Multiple logistic regressions revealed that women targeting “recommended weight gain advice” were 3 times more likely to meet total GWG recommendations (OR: 3.2, P < 0.05); women who complied with weekly GWG goals minimized PPWR (OR: 4.2, P < 0.02). In conclusion, appropriate GWG targets, lower energy intakes, and physical activity should be emphasized in prenatal education programs.

Maternal obesity during the preconception and early life periods alters pancreatic development in early and adult life in male mouse offspring

Maternal obesity induced by a high fat (HF) diet may program susceptibility in offspring, altering pancreatic development and causing later development of chronic degenerative diseases, such as obesity and diabetes. Female mice were fed standard chow (SC) or an HF diet for 8 weeks prior to mating and during the gestational and lactational periods. The male offspring were assessed at birth, at 10 days, and at 3 months of age. The body mass (BM) gain was 50% greater before pregnancy and 80% greater during pregnancy in HF dams than SC dams. Dams fed an HF diet showed higher oral glucose tolerance test (OGTT), blood pressure, serum corticosterone, and insulin levels than dams fed SC. At 10 days of age and at 3 mo old the HF offspring showed greater BM and higher blood glucose levels than the SC offspring. The mean diameter of the islets had increased by 37% in the SC offspring and by 155% in the HF offspring at 10 days of age. The islet mass ratio (IM/PM) was 88% greater in the HF offspring at 10 days of age, and 107% greater at 3 mo of age, compared to the values obtained at birth. The HF offspring had a beta cell mass (BCM)/PM ratio 54% lower than SC offspring at birth. However, HF offspring displayed a 146% increase in the BCM/PM ratio at 10 days of age, and 112% increase at 3 months of age than values at birth. A 3 mo of age, the HF offspring showed a greater OGTT and higher levels of than SC offspring. In conclusion, a maternal HF diet consumed during the preconceptional period and throughout the gestational and lactational periods in mice results in dramatic alterations in the pancreata of the offspring.

Maternal obesity promotes a proinflammatory signature in rat uterus and blastocyst

Maternal obesity at conception increases the risk of offspring obesity, thus propagating an intergenerational vicious cycle. Male offspring born to obese dams are hyperresponsive to high fat-diets, gaining greater body weight, fat mass, and additional metabolic sequelae compared to lean controls. In this report, we identify the impact of maternal obesity before conception, on the embryo, and intrauterine milieu during the periimplantation period. We conducted global transcriptomic profiling in the uterus and periimplantation blastocyst, gene/protein expression analyses of inflammatory pathways in conjunction with endocrine and metabolic characterization in the dams at implantation. Uterine gene expression profiles of lean and obese dams revealed distinct signatures for genes regulating inflammation and lipid metabolism. Both pathway and gene-set enrichment analysis revealed uterine nuclear factor-κB and c-Jun N-terminal kinase signaling to be up-regulated in the uterus of obese dams, which was confirmed via immunoblotting. Obese uteri also evidenced an inflammatory secretome with higher chemokine mRNA abundance (CCL2, CCL5, CCL7, and CxCL10) and related regulators (TLR2, CD14, and Ccr1). Increased inflammation in the uterus was associated with ectopic lipid accumulation and expression of lipid metabolic genes. Gene expression in sex-identified male periimplantation blastocyst at day postcoitum 4.5 was clearly influenced by maternal obesity (359 transcripts, ±1.4-fold), including changes in developmental and epigenetic regulators. Akin to the uterus, nuclear factor-κB-regulated proinflammatory genes (CCL4 and CCL5) increased and expression of antioxidant (GPx3) and mitochondrial (TFAM and NRF1) genes decreased in the obese embryos. Our results suggest that ectopic lipid and inflammation may link maternal obesity to increased predisposition of offspring to obesity later in life.

Implementation of the new institute of medicine gestational weight gain guidelines

In May 2009, the Institute of Medicine (IOM) introduced revised gestational weight gain guidelines that were based on balancing the benefits and risks of weight gain for both the mother and child's health. This article provides an overview of these new recommendations, explaining the key changes made from the previous 1990 IOM recommendations. The important role of health care providers of pregnant women in the implementation of the new recommendations is detailed, and specific guidance for troubleshooting issues that may be encountered when helping women achieve appropriate gestational weight gains is provided.

Maternal overweight programs insulin and adiponectin signaling in the offspring

Gestational exposure to maternal overweight (OW) influences the risk of obesity in adult life. Male offspring from OW dams gain greater body weight and fat mass and develop insulin resistance when fed high-fat diets (45% fat). In this report, we identify molecular targets of maternal OW-induced programming at postnatal d 21 before challenge with the high-fat diet. We conducted global transcriptome profiling, gene/protein expression analyses, and characterization of downstream signaling of insulin and adiponectin pathways in conjunction with endocrine and biochemical characterization. Offspring born to OW dams displayed increased serum insulin, leptin, and resistin levels (P < 0.05) at postnatal d 21 preceding changes in body composition. A lipogenic transcriptome signature in the liver, before development of obesity, was evident in OW-dam offspring. A coordinated locus of 20 sterol regulatory element-binding protein-1-regulated target genes was induced by maternal OW. Increased nuclear levels of sterol regulatory element-binding protein-1 and recruitment to the fatty acid synthase promoter were confirmed via ELISA and chromatin immunoprecipitation analyses, respectively. Higher fatty acid synthase and acetyl coenzyme A carboxylase protein and pAKT (Thr(308)) and phospho-insulin receptor-beta were confirmed via immunoblotting. Maternal OW also attenuated AMP kinase/peroxisome proliferator-activated receptor-alpha signaling in the offspring liver, including transcriptional down-regulation of several peroxisome proliferator-activated receptor-alpha-regulated genes. Hepatic mRNA and circulating fibroblast growth factor-21 levels were significantly lower in OW-dam offspring. Furthermore, serum levels of high-molecular-weight adiponectin (P < 0.05) were decreased in OW-dam offspring. Phosphorylation of hepatic AMP-kinase (Thr(172)) was significantly decreased in OW-dam offspring, along with lower AdipoR1 mRNA. Our results strongly suggest that gestational exposure to maternal obesity programs multiple aspects of energy-balance regulation in the offspring.

Household food insecurity is associated with self-reported pregravid weight status, gestational weight gain, and pregnancy complications

BACKGROUND

Household food insecurity is positively associated with weight among women. The association between household food insecurity and pregnancy-related weight gain and complications is not well understood.

OBJECTIVE

To identify whether an independent association exists between household food insecurity and pregnancy-related complications.

DESIGN

Data from the Pregnancy, Infection, and Nutrition prospective cohort study were used to assess household food insecurity retrospectively using the US Department of Agriculture 18-item Core Food Security Module among 810 pregnant women with incomes < or =400% of the income/poverty ratio, recruited between January 2001 and June 2005 and followed through pregnancy.

MAIN OUTCOME MEASURES

Self-reported pregravid body mass index, gestational weight gain, second trimester anemia, pregnancy-induced hypertension, and gestational diabetes mellitus.

STATISTICAL ANALYSES PERFORMED

Multivariate linear, multinomial logistic, and logistic regression analyses.

RESULTS

Among 810 pregnant women, 76% were from fully food secure, 14% were from marginally food secure, and 10% were from food insecure households. In adjusted models, living in a food insecure household was significantly associated with severe pregravid obesity (adjusted odds ratio 2.97, 95% confidence intervals [CIs] 1.44 to 6.14), higher gestational weight gain (adjusted beta coefficient 1.87, 95% CI 0.13 to 3.62), and with a higher adequacy of weight gain ratio (adjusted beta .27, 95% CI 0.07 to 0.50). Marginal food security was significantly associated with gestational diabetes mellitus (adjusted odds ratio 2.76, 95% CI 1.00 to 7.66).

CONCLUSIONS

This study highlights the possibility that living in a food insecure household during pregnancy may increase risk of greater weight gain and pregnancy complications.

Trends in birth weight and gestational length among singleton term births in the United States: 1990-2005

OBJECTIVE

To estimate changes over time in birth weight for gestational age and in gestational length among term singleton neonates born from 1990 to 2005.

METHODS

We used data from the U.S. National Center for Health Statistics for 36,827,828 singleton neonates born at 37-41 weeks of gestation, 1990-2005. We examined trends in birth weight, birth weight for gestational age, large and small for gestational age, and gestational length in the overall population and in a low-risk subgroup defined by maternal age, race or ethnicity, education, marital status, smoking, gestational weight gain, delivery route, and obstetric care characteristics.

RESULTS

In 2005, compared with 1990, we observed decreases in birth weight (-52 g in the overall population, -79 g in a homogenous low-risk subgroup) and large for gestational age birth (-1.4% overall, -2.2% in the homogenous subgroup) that were steeper after 1999 and persisted in regression analyses adjusted for maternal and neonate characteristics, gestational length, cesarean delivery, and induction of labor. Decreases in mean gestational length (-0.34 weeks overall) were similar regardless of route of delivery or induction of labor.

CONCLUSION

Recent decreases in fetal growth among U.S., term, singleton neonates were not explained by trends in maternal and neonatal characteristics, changes in obstetric practices, or concurrent decreases in gestational length.

LEVEL OF EVIDENCE

III.

New intrauterine growth curves based on United States data

OBJECTIVE

The objective of this study was to create and validate new intrauterine weight, length, and head circumference growth curves using a contemporary, large, racially diverse US sample and compare with the Lubchenco curves.

METHODS

Data on 391 681 infants (Pediatrix Medical Group) aged 22 to 42 weeks at birth from 248 hospitals within 33 US states (1998-2006) for birth weight, length, head circumference, estimated gestational age, gender, and race were used. Separate subsamples were used to create and validate curves. Smoothed percentile curves (3rd to 97th) were created by the Lambda Mu Sigma (LMS) method. The validation sample was used to confirm representativeness of the curves. The new curves were compared with the Lubchenco curves.

RESULTS

Final sample included 257 855 singleton infants (57.2% male) who survived to discharge. Gender-specific weight-, length-, and head circumference-for-age curves were created (n = 130 111) and successfully validated (n = 127 744). Small-for-gestational age and large-for-gestational age classifications using the Lubchenco curves differed significantly from the new curves for each gestational age (all P < .0001). The Lubchenco curves underestimated the percentage of infants who were small-for-gestational-age except for younger girls (< or =36 weeks), for whom it was more likely to be overestimated; underestimated percentage of infants (< or =36 weeks) who were large-for-gestational-age; and overestimated percentage of infants (>36 weeks) who were large-for-gestational-age.

CONCLUSIONS

The Lubchenco curves may not represent the current US population. The new intrauterine growth curves created and validated in this study, based on a contemporary, large, racially diverse US sample, provide clinicians with an updated tool for growth assessment in US NICUs. Research into the ability of the new definitions of small-for-gestational-age and large-for-gestational-age to identify high-risk infants in terms of short-term and long-term health outcomes is needed.

Early life influences on obesity risk: maternal overnutrition and programming of obesity

While adult lifestyle factors undoubtedly contribute to the incidence of obesity and its attendant disorders, mounting evidence suggests that programming of obesity may occur following over-nutrition during development. As hypothalamic control of appetite and energy expenditure is set early in life and can be perturbed by certain exposures, such as undernutrition and altered metabolic and hormonal signals, in utero exposure to maternal obesity-related changes may contribute to programming of obesity in offspring. Data from animal studies indicate both intrauterine and postnatal environments are critical determinants of the development of pathways regulating energy homeostasis. This review summarizes recent evidence of the impact of maternal obesity on subsequent obesity risk, paying particular attention to the hypothalamic regulation of appetite and markers of metabolic control. The extraordinary rise in the rates of maternal obesity underlines an urgent need to investigate the mechanisms contributing to its transgenerational effects.

The effect of obesity on neuraxial technique difficulty in pregnant patients: a prospective, observational study

BACKGROUND

Practitioners often presuppose that obesity will increase neuraxial technique difficulty in pregnant patients, but few investigators have systematically examined this population for risk factors associated with difficult epidural or spinal needle placement. We designed this study to prospectively identify factors that predict neuraxial technique difficulty in pregnant patients.

METHODS

Using a prospective, observational format, pregnant patients were examined for multiple potential risk factors for neuraxial technique difficulty, including current body mass index, ability to palpate spinous processes, maximum back flexion, scoliosis, and experience of the practitioner. Neuraxial technique difficulty was then assessed using two measures: 1) the number of needle passes needed to reach the desired space, and 2) the placement time from skin infiltration to either spinal injection or epidural catheter threading. Predictors of total needle passes were determined by fitting the data to a generalized linear model with negative binomial error. Predictors of neuraxial anesthetic time were determined by fitting a linear model to the log of neuraxial anesthetic placement time. A survival model was used to account for bias introduced when attending physicians intervened in resident physician procedures.

RESULTS

Neuraxial procedures in 427 pregnant patients were studied. For both the number of needle passes and the neuraxial anesthetic placement time, the significant predictors of difficulty were the practitioner's ability to palpate the patient's bony landmarks and the patient's ability to flex her back. Obesity, as measured by body mass index, was not an independent predictor of either end point. Obesity did, however, strongly predict both the ability to palpate landmarks and flex the back.

CONCLUSIONS

Despite concerns that obesity may cause difficulty with neuraxial technique, some obese patients have surprisingly easy neuraxial block placements. When approaching any neuraxial anesthetic in a pregnant patient, and especially in the obese parturient, back flexion and landmark palpation predict neuraxial technique difficulty.

[Increased rate of Caesarean sections--causes and consequences]

BACKGROUND

A rise in the rate of caesarean sections has been observed in most parts of the developed world during the last decades. Causes and consequences are much debated.

MATERIAL AND METHODS

Non-systematic literature search in PubMed.

RESULTS

The increased rate of caesarean sections can be explained by both medical non-medical factors. Among the medical factors are increases in maternal age and body mass index, as well as changes in obstetric practise and technology. Some non-medical factors are caesarean section requested by the mother, fear of litigation among caregivers and inappropriate organization of maternity care. Caesarean section is associated with maternal postpartum morbidity, reduced fertility and placental complications in a subsequent pregnancy. For the child, caesarean section is associated with postpartum respiratory morbidity, less breast-feeding and possibly more atopic disease. For society, caesarean section is more costly than vaginal delivery.

INTERPRETATION

There are many and complex causes of the rise in caesarean section rates in industrialized countries. The procedure has inherent negative consequences (short- and long-term) for mother and child, as well as being an economic burden to society. There is every reason to attempt prevention of a further increase in caesarean section rates.

Population-Based Analysis of Hypertensive Disorders in Pregnancy

OBJECTIVE

To determine the population-based incidence of hypertensive diseases in pregnancy in Western New York.

METHODS

A database of 77,358 women with singleton pregnancies was analyzed using birth certificate data. The incidence of pregnancies complicated by gestational hypertension, preeclampsia, and eclampsia was determined.

RESULTS

The overall incidence of pregnancy-associated hypertensive disease varied slightly from 1999 to 2003. The incidence of preeclampsia decreased from 1.8% to 1.1% (p < 0.01). This decrease persisted over time, despite controlling for known risk factors, such as body mass index, age, ethnicity, parity, smoking, diabetes, and chronic hypertension.

CONCLUSION

The incidence of pregnancy-related hypertensive disorders slightly decreased in our population in the last 5 years, with a decline in the rate of preeclampsia accounting for this change. Further analysis may provide additional insights into the population-based incidence of preeclampsia.

Triplet gestation outcomes in relation to maternal prepregnancy body mass index and weight gain

OBJECTIVE

To study prepregnancy maternal body mass index (BMI) and overall maternal weight gain in triplet gestations in relation to maternal and newborn outcomes.

STUDY DESIGN

This was a retrospective study of birth certificate data of all live-born triplet gestations occurring between 1999 and 2003 in an eight-county region in New York. An analysis of computerized birth certificate data for variables related to pregnancy and newborn outcomes was conducted, looking at neonatal birth weight, neonatal gestational age, and the occurrence of the maternal pregnancy complications of gestational diabetes, gestational hypertension, and preeclampsia.

RESULTS

In 56 triplet gestations studied, the prepregnancy BMI was not associated with mean newborn birth weights and gestational age at delivery. The total maternal weight gain was associated with increasing mean birth weight and higher gestational age at delivery. Pregnancy complications in triplet pregnancies of gestational diabetes and gestational hypertension were associated with prepregnancy BMI, but not maternal weight gain.

CONCLUSION

For triplet gestations, a normal prepregnancy BMI and a total gestational weight gain of at least 15.9 - 20.5 kg (35 - 45 lb) are associated with fewer pregnancy complications.

Should access to fertility-related services be conditional on body mass index?

Guidelines for the clinical management of obese, reproductive age women with reduced fertility in the USA are limited. Clinical professional organizations have yet to publish practice guidelines on this topic. Thus, treatment decisions are made at the provider and/or clinic level and the variation in clinic policy regarding fertility treatment for obese women is not readily available. Globally, there is an ongoing discussion among reproductive endocrinologists that practice in countries with government-funded health care about whether treatment should be restricted to women under a certain body mass index. Our analysis of a representative US population identified that differences exist in the utilization of fertility-related services according to female body mass. Women with class II/III obesity were the group reporting the highest percentage seeking medical attention to become pregnant, but the lowest percentage receiving medical or surgical fertility-related services, although these differences were not statistically significant. As the prevalence of obesity among women of reproductive age increases both in the USA and abroad, it is critical to consider the medical, social and ethical issues involved in allocating resources for fertility treatment. Ongoing monitoring of trends in service utilization in light of the obesity epidemic and delayed childbearing will provide further insight into this clinical health policy issue.

Accuracy of breastfeeding data on the Massachusetts birth certificate

In 2003, the question, "Is the infant being breastfed at discharge?" was added to the US standard certificate of live birth. In Massachusetts, this was adapted to, "Are you breastfeeding or do you intend to?" In 2004-5, we compared the mother's answer to the birth certificate question in 2 hospitals, with her infant's feeding record. At Hospital A, 94.8% (290/306) of birth certificate responses matched the record. At (Baby-Friendly) Hospital B, 79.8% (185/232) matched. At the Baby-Friendly hospital, 17.2% (40/232) of women stated intent to formula feed on the birth certificate but breastfed postpartum. No significant sociodemographic differences existed between women whose answers matched or did not match. Although breastfeeding is a desirable health behavior, mothers did not overstate intent. The assumption that a prenatal feeding decision is an independent predictor of breastfeeding practice may be flawed. In the Baby-Friendly hospital, many women apparently made the decision postpartum.

Pregravid weight is associated with prior dietary restraint and psychosocial factors during pregnancy

The objective of this study was to investigate the association of pregravid weight status, previous dietary restraint, and psychosocial factors during pregnancy. We used data from the Pregnancy, Infection, and Nutrition study, which recruited 2,006 women at prenatal clinics before 20 weeks' gestation who were >16 years and English speaking. Institute of Medicine BMI cut points of underweight (<19.8), normal weight (19.8-26.0), overweight (>26.0-29.0), obese (>29.0-34.9), and an additional category extremely obese (> or =35.0), were used to categorize weight status. Eight psychosocial measures and dietary restraint were assessed with regard to BMI; perceived stress, trait anxiety, depressive symptoms, internal locus of control (LOC), chance LOC, powerful others LOC, self-esteem, and mastery. Linear regression was used to estimate associations, controlling for potential confounders. A significant trend was found between increasing pregravid weight categories and increasing scores for perceived stress, trait anxiety, depressive symptoms, powerful others LOC and dietary restraint, and decreasing scores for self-esteem and mastery. In adjusted models, pregravid obesity was independently associated with perceived stress, trait anxiety, and depressive symptoms. Extreme obesity was independently associated with all measures except internal LOC. A strong linear association was found between increasing weight categories and dietary restraint. In conclusion, as pregravid weight increased, pregnant women were at greater risk of reporting higher scores on negative psychosocial state and dietary restraints, and reporting lower score on positive personal dispositions.

Obesity as a complication of pregnancy and labor

Over the last 40 years, there have been significant increases in the rates of overweight and obesity in childbearing women. There has been a parallel increase in the rates of pregnancy complications including hypertension, diabetes, fetal macrosomia, and complications of delivery. Caregivers can focus on appropriate interventions during pregnancy and childbirth to improve outcomes and prevent harm.

Established maternal obesity in the rat reprograms hypothalamic appetite regulators and leptin signaling at birth

OBJECTIVE

Key appetite regulators and their receptors are already present in the fetal hypothalamus, and may respond to hormones such as leptin. Intrauterine food restriction or hyperglycemia can reprogram these circuits, possibly predisposing individuals to adverse health outcomes in adulthood. Given the global obesity epidemic, maternal overweight and obesity is becoming more prevalent. Earlier, we observed rapid growth of pups from obese dams during the suckling period. However, it is unclear whether this is because of alterations in leptin and hypothalamic appetite regulators at birth.

DESIGN

Female Sprague-Dawley rats were fed palatable high-fat diet (HFD) or chow for 5 weeks to induce obesity before mating. The same diet continued during gestation. At day 1, after birth, plasma and hypothalamus were collected from male and female pups.

MEASUREMENTS

Body weight and organ mass were recorded. Leptin and insulin levels were measured in the plasma by radioimmunoassay. Hypothalamic mRNA expression of neuropeptide-Y (NPY), pro-opiomelanocortin, leptin receptor and its downstream signal, STAT3 (signal transducer and activator of transcription 3), were measured using real-time PCR.

RESULTS

Body and organ weights of pups from obese dams were similar to those from lean dams, across both genders. However, plasma leptin levels were significantly lower in offspring from obese dams (male: 0.53+/-0.13 vs 1.05+/-0.21 ng ml(-1); female: 0.33+/-0.09 vs 2.12+/-0.57 ng ml(-1), respectively; both P<0.05). Hypothalamic mRNA expression of NPY, pro-opiomelanocortin, leptin receptor and STAT3 were also significantly lower in pups from obese dams.

CONCLUSION

Long-term maternal obesity, together with lower leptin levels in pups from obese dams may contribute to the lower expression of key appetite regulators on day 1 of life, suggesting altered intrauterine neuron development in response to intrauterine overnutrition, which may contribute to eating disorders later in life.

Obesity in pregnancy: pre-conceptional to postpartum consequences

OBJECTIVE

To review the effects of obesity on reproduction and pregnancy outcome.

METHODS

A search of the literature was performed using key word searching and citation snowballing to identify English language articles published between January 1, 2000, and December 31, 2006, on the subject of obesity and its effects on pregnancy. Once the articles were identified, a thorough review of all results was conducted. Results and conclusions were compiled and summarized.

RESULTS

Obesity during pregnancy was linked with maternal complications ranging from effects on fertility to effects on delivery and in the postpartum period, as well as many complications affecting the fetus and newborn. The maternal complications associated with obesity included increased risks of infertility, hypertensive disorders, gestational diabetes mellitus, and delivery by Caesarean section. Fetal complications included increased risks of macrosomia, intrauterine fetal death and stillbirth, and admission to the neonatal intensive care unit.

CONCLUSION

Obesity causes significant complications for the mother and fetus. Interventions directed towards weight loss and prevention of excessive weight gain must begin in the pre-conception period. Obstetrical care providers must counsel their obese patients regarding the risks and complications conferred by obesity and the importance of weight loss. Maternal and fetal surveillance may need to be heightened during pregnancy; a multidisciplinary approach is useful. Women need to be informed about both maternal and fetal complications and about the measures that are necessary to optimize outcome, but the most important measure is to address the issue of weight prior to pregnancy.

Prepregnancy obesity prevalence in the United States, 2004-2005

OBJECTIVE

To provide a current estimate of the prevalence of prepregnancy obesity in the United States.

METHODS

We analyzed 2004-2005 data from 26 states and New York City (n = 75,403 women) participating in the Pregnancy Risk Assessment Monitoring System, an ongoing, population-based surveillance system that collects information on maternal behaviors associated with pregnancy. Information was obtained from questionnaires self-administered after delivery or from linked birth certificates; prepregnancy body mass index was based on self-reported weight and height. Data were weighted to provide representative estimates of all women delivering a live birth in each particular state.

RESULTS

In this study, about one in five women who delivered were obese; in some state, race/ethnicity, and Medicaid status subgroups, the prevalence was as high as one-third. State-specific prevalence varied widely and ranged from 13.9 to 25.1%. Black women had an obesity prevalence about 70% higher than white and Hispanic women (black: 29.1%; white: 17.4%; Hispanic: 17.4%); however, these race-specific rates varied notably by location. Obesity prevalence was 50% higher among women whose delivery was paid for by Medicaid than by other means (e.g., private insurance, cash, HMO).

CONCLUSION

This prevalence makes maternal obesity and its resulting maternal morbidities (e.g., gestational diabetes mellitus) a common risk factor for a complicated pregnancy.

Association of intrauterine exposure to maternal diabetes and obesity with type 2 diabetes in youth: the SEARCH Case-Control Study

OBJECTIVE

Limited data exist on the association between in utero exposure to maternal diabetes and obesity and type 2 diabetes in diverse youth. These associations were explored in African-American, Hispanic, and non-Hispanic white youth participating in the SEARCH Case-Control Study.

RESEARCH DESIGN AND METHODS

A total of 79 youth with type 2 diabetes and 190 nondiabetic control youth aged 10-22 years attended a research visit. In utero exposures to maternal diabetes and obesity were recalled by biological mothers.

RESULTS

Youth with type 2 diabetes were more likely to have been exposed to maternal diabetes or obesity in utero than were nondiabetic control youth (P < 0.0001 for each). After adjusting for offspring age, sex, and race/ethnicity, exposure to maternal diabetes (odds ratio [OR] 5.7 [95% CI 2.4-13.4]) and exposure to maternal obesity (2.8 [1.5-5.2]) were independently associated with type 2 diabetes. Adjustment for other perinatal and socioeconomic factors did not alter these associations. When offspring BMI was added, the OR for the association between in utero exposure to obesity and type 2 diabetes was attenuated toward the null (OR 1.1 [0.5-2.4]). Overall, 47.2% (95% CI 30.9-63.5) of type 2 diabetes in youth could be attributed to intrauterine exposure to maternal diabetes and obesity.

CONCLUSIONS

Intrauterine exposures to maternal diabetes and obesity are strongly associated with type 2 diabetes in youth. Prevention efforts may need to target, in addition to childhood obesity, the increasing number of pregnancies complicated by obesity and diabetes.

Cardiovascular and metabolic effects of obesity

1. Obesity is an important risk factor for hypertension and its incidence is increasing around the world. 2. The mechanisms underlying obesity-related hypertension include sympathetic activation, altered vascular responses, hormonal changes, enhanced inflammatory markers and structural changes. 3. This review summarizes recent evidence of the underlying impact of obesity on blood pressure. A number of candidate mechanisms include increased sympathetic activity, activation of the renin-angiotensin system, altered vasoconstrictor or dilator responses and the attendant systemic inflammatory state. 4. While adult lifestyle factors undoubtedly contribute to the incidence of obesity and its attendant hypertension, evidence suggests that the programming of obesity may occur following over-nutrition during development. A growing body of evidence links maternal obesity, offspring obesity and hypertension. 5. Finally, epigenetic modification of genes relevant to hypertension may contribute to the development of hypertension following a suboptimal intrauterine environment. To date the cardiovascular effects of early nutritional changes have been largely investigated following maternal under-nutrition or protein restriction; further work is necessary to determine the impact of maternal obesity.