Matern Child Health J (2009) 13:839–846 DOI 10.1007/s10995-008-0413-6
Maternal Weight Gain During Pregnancy and Child Weight at Age 3 Years Christine M. Olson Æ Myla S. Strawderman Æ Barbara A. Dennison
Published online: 26 September 2008 Ó Springer Science+Business Media, LLC 2008
Abstract Objectives To determine the importance of pregnancy weight gain as a predictor of overweight (Body Mass Index [BMI] [85th percentile) in offspring at age 3 years and if its influence varies by maternal BMI. Methods Chi-square and logistic regression analyses were conducted on a sample of 208 mother-child pairs from an earlier observational cohort study on postpartum weight retention. Results In the final reduced regression model, maternal early pregnancy BMI was positively and significantly associated with overweight in offspring, as were birth weight above the sample median of 3,600 g and maternal smoking during pregnancy (P B 0.01). In addition, a significant interaction was found between maternal BMI and gestational weight gain (P = 0.03). The risk of offspring overweight that is associated with 5 excess pounds of net pregnancy weight gain increases with maternal BMI. Conclusions Excess pregnancy weight gain is associated with increased risk of child overweight at age 3 years and its impact is greater among high and obese BMI women than it is in normal BMI women. Reducing maternal BMI in the preconception period in overweight women and preventing excessive weight gain in pregnancy for all women appear to be appropriate strategies to address the childhood obesity epidemic. C. M. Olson (&) M. S. Strawderman Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA e-mail:
[email protected] M. S. Strawderman e-mail:
[email protected] B. A. Dennison Research Institute, Bassett Healthcare, Cooperstown, NY 13326-1394, USA e-mail:
[email protected]
Keywords Pregnancy Weight gain Child Preschool Obesity Body mass index (BMI)
Introduction Obesity and overweight are prevalent conditions among children in the US. In 2003–2004, 17.1% of children and adolescents age 2 through 19 years had a body mass index (BMI) [95th percentile for their age and sex and were defined as overweight, as were 13.9% of 2 through 5 yearold children [1]. Being obese is associated with health problems such as type 2 diabetes, hypertension, and dyslipidemia in the pediatric age group, but it is also a significant risk factor for adult morbidity and mortality [2]. Obesity and overweight tends to persist from the preschool years to age 12 years and beyond [3]. Among children in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development, those whose BMI was [85th percentile (i.e. overweight) at one or more times from 24 months to 54 months, were more than 5 times more likely to be overweight age at 12 years of age than those whose BMI was below the 85th percentile in the preschool years. There is growing interest in, and acceptance of, the idea that there are critical or sensitive periods for the development of obesity across the life course. Several recent reviews of the literature and editorials have highlighted the role of the prenatal period in the development of childhood obesity [4–6]. Lawlor and Chaturvedi [6] recently concluded that the evidence supporting a role for intrauterine over-nutrition in predicting life long obesity is increasing. Two recent studies of preschool children have shown that maternal pre- or early-pregnancy obesity was related to increased risk of obesity (BMI [95th percentile). In a
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sample of low-income children who participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Ohio, Whitaker [7] showed that maternal obesity in the first trimester of pregnancy doubles the risk of obesity among children between the ages of 2 through 4 years. Using data from the National Longitudinal Survey of Youth, Salsberry and Reagan [8] showed maternal pre-pregnancy obesity (BMI C30) increased the risk of children, aged 2 through 4 years, having a BMI above the 95th percentile by about 40% compared to children whose mothers had a BMI in the normal range (18.5–24.9). Several recent studies have shown an independent effect of pregnancy weight gain on overweight and obesity in children [9, 10]. Oken et al. [9] showed that women with adequate or excessive weight gain in pregnancy had an approximately 4-fold increased odds of having a child who had a BMI C95th percentile (vs. BMI \the 50th percentile) compared to women with inadequate weight gain. Investigators in Portugal [10] have also shown that children of mothers who gained C16 kg in pregnancy were more likely to be overweight or obese during the elementary school years than children born to mothers who gained \9 kg during pregnancy. In one study that has only been published as an abstract, the impact of pregnancy weight gain on childhood risk of obesity was modified by maternal pre-pregnancy BMI [11]. The purpose of the research reported here was to further examine the importance of gestational or pregnancy weight gain as a predictor of overweight (defined as BMI [85th percentile) in offspring during the preschool years and to determine whether the influence of this factor varies by maternal early pregnancy (first trimester) BMI. New information suggests that the prevalence of gaining more weight in pregnancy than is recommended by the Institute of Medicine is about 40% in the general population [12– 14] and is as high as 67% in low-income, minority populations [15]. In addition, research demonstrates that with appropriate intervention, excessive gestational weight gain can be prevented without harming infants [16, 17].
Methods Population and Sample This study used data from the Bassett Mothers Health Project (BMHP), one component of a larger, NIH-funded project, ‘‘Biosocial Influences on Postpartum Weight Retention’’ (Grant No. HD 29549). The BMHP was an observational cohort study of 622 women followed from early pregnancy until two years postpartum. Women were recruited from the population registering for prenatal care
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at Bassett Healthcare’s network of primary care clinics in an 8-county area of rural upstate New York. All women entering care were screened for eligibility and eligible women were recruited for participation. To be eligible for participation in this study, women needed to be healthy, reach the age of 18 years by the time of delivery, plan to deliver at the Bassett Hospital, and keep the infant. Once the women had delivered an additional eligibility criterion was applied—giving birth to a live singleton infant. Twenty-five percent of eligible women actively or tacitly refused participation. Additional eligibility and participation details are described elsewhere [18, 19]. Of the 622 women, 603 (96.9%) delivered infants with birth weights of 2,500 grams or higher (not low birth weight). The medical records of 256 of these women’s children were located at selected clinics. Since resources for travel to the most distant outreach clinics were limited, we selected those clinics closest to the main site with the largest number of children to include in this study. Twohundred and eight children were not low birth weight, had a weight available at 3 years, and had medical record numbers that matched the newborns’ medical record number indicated in the mothers’ charts. These 208 children and their mothers are the sample for this study. The study was approved by the University Committee on Human Subjects of Cornell University and the Institutional Review Board of Bassett Healthcare. Data Collection For the BMHP, three methods of data collection were employed. The women were mailed questionnaires at each of the following time points: first or second trimester of pregnancy, 6 months postpartum, 1 and 2 years postpartum. Shortly after delivery, the women’s obstetrical records were audited and data entered directly into a computer. In addition, women’s weight and height were measured following study protocols by health care providers at antenatal visits and at 1 and 2 years postpartum. The obstetrical record is the primary source for the data included in this paper. The breastfeeding data come from the questionnaires. When most of the children born to women in the BMHP had reached the age of 5 years, we audited the medical records of 256 children at selected clinics. We extracted information on children’s weights and lengths or heights at 1, 3 and 5 years of age. These measures had been taken in the context of well-child care by the pediatric staff of the clinics. Measures and Variables The specific methods and instruments used in the BMHP are described in detail in a previous publication [20] and
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described briefly here. For mothers, body mass index (BMI) was used as a continuous variable and also to determine body weight status categories. Using the first measured weight in the first trimester of pregnancy to calculate BMI, women’s body weight status was classified as low, normal, high, or obese using the Institute of Medicine (IOM) BMI categories: Low or underweight (\19.8), normal (19.8 to 26.0), high or overweight (26.1–29.0), and obese ([29.0) [21]. For some of the analyses, low and normal BMI women were combined into one group (not overweight) and the high and obese BMI women were combined into a single group (overweight). Gestational weight gain was expressed as gaining less weight than recommended, the recommended amount, or more than the recommended amount according to the IOM BMI categories and gestational weight gain guidelines e.g. 25–35 pounds for a normal BMI woman [21]. Net gestational weight gain was used as a continuous variable and was calculated by subtracting infant birth weight from total gestational weight gain. Household income level was categorized as low income (B185% of the federal poverty line) or not low income ([185% of the federal poverty line.) Additional variables considered as potentially confounding variables in the relationship between maternal weight characteristics and child overweight included: smoking during pregnancy (yes/no); exclusive breastfeeding for at least 6 months (yes/no); parity (nulliparous/ parous); and infant birth weight (expressed in grams and used as the categories of above and below the median birth weight for the sample). The children’s BMI percentile was determined by a SAS program available on the Centers for Disease Control and Prevention (CDC) growth charts web page and based on the CDC growth reference for 2000 (www.cdc.gov/nccdphp/dnpa/growthcharts/resources/sas. htm). Children with a BMI percentile [the 85th sexspecific percentile for age were defined as overweight. Data Analysis Chi square analyses were conducted to compare the analysis sample to the population-based sample from which it came in order to identify any factors that may have shifted due to sample selection. Fisher’s Exact test was used to compare the proportion of children whose BMI was [85th percentile by maternal weight characteristics (not shown). Logistic regression models were developed for predicting overweight in children controlling for potentially confounding factors. Because some of the continuous predictors were correlated, such as net gestational weight gain and BMI, these maternal weight factors were centered at the mean to reduce the effect of collinearity. In building the logistic regression models, first, the maternal factors were included singly, only adjusting for gestational age of
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the infant (length of pregnancy). Next, a full main effects model, including all the factors evaluated in the first univariate step, was fit. All two-way interactions in the full model were assessed and included in the final model if the p-value associated with the factor was B0.05. Finally, this model was reduced in a backward elimination procedure, starting with the least significant factor, and removing factors until all remaining were significant at the 0.05 level or were supporting a significant higher order interaction. An equation for estimating risk of overweight in children for hypothetical women with different BMI categories (normal, high and obese) and net gestational weight gains was developed from the final reduced logistic regression model. The equation is shown below: Estimated OR ¼ ð1:112ÞðBMInewBMIref Þ ð1:007ÞðGWGnewGWGref Þ ð1:006ÞðBMInewGWGnewÞðBMIrefGWGref Þ Results Description of the Sample The characteristics of the population-based sample and the sample used in these analyses are shown in Table 1. For the analysis sample, the main pediatric clinic at Bassett Healthcare is over-represented in the analysis sample compared to the population sample. The analysis sample has a lower proportion of low income children than the population sample (33.8% vs. 44.0%; P = 0.003) and a higher proportion of mothers who were overweight in early pregnancy (38.5% vs. 26.4%; P \ 0.0001). On all other characteristics, the two samples were similar. In particular, they did not differ on the proportion of mothers who gained more than the recommended amount of weight in pregnancy (P = 0.30). Thus the sample, while only a portion of the original sample, is a reasonable one for investigating the relationship between maternal and child weight characteristics. Associations Between Maternal Weight Characteristics and Weight of Children Children whose mothers who were overweight (high and obese maternal BMI combined) in early pregnancy were significantly more likely to have a BMI above the 85th percentile (defined as overweight) at 3 years than children whose mothers were not overweight (low and normal BMI combined) in early pregnancy (40.0% vs. 24.2%; P = .02), as shown in Fig. 1. Among children whose mothers were overweight in early pregnancy, gaining more weight in pregnancy than is recommended by the Institute of Medicine (IOM) was not significantly associated with overweight at
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Matern Child Health J (2009) 13:839–846 Child OVWT (3yr) 30.3% (n=208)
Table 1 Characteristics of population and analysis samples Characteristic Clinic site
Population sample N = 603
Analysis sample N = 208
(missing = 107)
Bassett
188 (37.9)
122 (58.7)
Cobleskill
93 (18.8)
36 (17.3)
Oneonta
117 (23.6)
48 (23.1)
Sharon springs
0
2 (1.0)
Other
98 (19.8)
0
Maternal characteristics Overweight in early pregnancy* Yes
159 (26.4)
80 (38.5)
No
444 (73.6)
128 (61.5)
Yes
247 (41.0)
78 (37.5)
No
356 (59.0)
128 (61.5)
(missing = 12)
(missing = 1)
Yes
260 (44.0)
70 (33.8)
No
331 (56.0)
137 (66.2)
117 (19.4) 486 (80.6)
30 (14.4) 178 (85.6)
Yes
249 (41.4)
80 (38.5)
No
353 (58.6)
128 (61.5)
(missing = 87)
(missing = 22)
Yes
122 (23.6)
42 (22.6)
No
394 (76.3)
144 (77.4)
Pregnancy weight gain [recommended
Low income*
Smoking during pregnancy Yes No
Mom OVWT 40.0% (n=80) GWG>IOM 47.5% (n=40)
GWG≤IOM 32.5% (n=40)
Mom not OVWT 24.2% (n=128) GWG>IOM 23.7% (n=38)
GWG≤IOM 24.4% (n=90)
Fig. 1 Proportion of overweight (OVWT) children at age 3 years by maternal overweight (OVWT) and gestational weight gain (GWG)
3 years while only 23.7% of children with normal or underweight mothers were overweight at 3 years (P = 0.03). Examining only the overweight women, among the obese women within this group, gaining more weight in pregnancy than is recommended by the IOM was significantly associated with a higher prevalence of offspring overweight at age 3 years (66.7% vs. 37.5%; P = .05), while this relationship was not statistically significant among the high BMI women within this group. Some significant associations of birth weight and childhood overweight were also found. Among overweight women who did not gain excessively in pregnancy, birth weight above the median for this sample (3,600 g) was significantly associated with overweight at 3 years (52.9% vs. 17.4%; P = .02).
Nulliparous
Exclusively breastfed at least 6 months
Baby characteristics Sex Male
(missing = 4) 317 (52.9)
101 (48.7)
282 (47.1) (missing = 1)
107 (51.4)
1
249 (41.4)
80 (38.5)
2
205 (34.1)
78 (37.5)
3 or later
148 (24.6)
50 (24.0)
Yes
136 (22.6)
49 (23.6)
No
467 (77.5)
159 (76.4)
Female Birth order
Adjusted Maternal Weight Predictors of Overweight in Childhood The results of the multivariable analyses including the suggested interaction between maternal body weight and gestational weight gain (net gestational weight gain because birth weight is also in the model) are show in Table 2. In this model, maternal BMI is a continuous factor Table 2 Multivariate models of predictors of childhood overweight at age 3 years
Birth weight [4,000 g
Birth weight (g) Mean (SD)
3622.9 (499.2)
3623.3 (492.7)
* P \ 0.05
Full model*
Reduced model*
R2 = 23%
R2 = 20%
OR Maternal (m) BMI1
P-value OR
1.109 .003
P-value
1.112 .001
Net gestational weight gain (GWG) 1.009 .6
1.007 .7
mBMI 9 Net GWG
1.005 .05
1.006 .03
Birth weight (C3,600 g) Low income
3.001 .004 1.243 .6
3.236 .002
Exclusive breastfeeding C6 months 1.733 .2
3 years (47.5% vs. 32.5%; P = .17). Similarly, no significant relationship between gestational weight gain and childhood overweight was observed in the mothers who were not overweight in early pregnancy (23.7% vs. 24.4%; P = .90). Among women who gained excessively, 47.5% of the children of overweight mothers were overweight at
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Smoking in pregnancy
3.121 .02
3.103 .01
* Gestational age is included in the models as a control variable and is not significant Notes: OR = model estimated odds ratio per unit change; R2 = Maxrescaled R-square statistic; P-value = P-value for the test that the OR = 1
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as is net gestational weight gain. In the full and reduced models, maternal BMI was positively and significantly associated with overweight (BMI [85th percentile) in the offspring at age 3 years. Net gestational weight gain was not significantly associated with childhood overweight, but interacted significantly with maternal BMI in the full and the reduced model (P = 0.05 and 0.03 respectively). Birth weight and maternal smoking during pregnancy were also associated with children having a BMI above the 85th percentile, as expected, and neither family income nor exclusive breastfeeding until 6 months were significantly related to overweight in children. Illustration of the Impact of Maternal BMI and Net Gestational Weight Gain on Risk of Overweight in Children The odds ratios for overweight at age 3 years shown in Table 3 were derived from the reduced model in Table 2. In column 1 of Table 3, we show as the reference woman to whom all other women were compared, a normal weight woman (BMI = 23) who if she had a median weight infant for our sample (3,600 g or 8 pounds) would have gained within the recommended range of gestational weight gain according to the IOM. For women with a normal early pregnancy BMI, a net gestational weight gain of 15 pounds (gaining less than recommended with the median birth weight infant), the odds of their children being overweight at age 3 years is less than half that of the reference women who gained within the range. For women with a normal early pregnancy BMI who had net gestational weight gains of 30 pounds (gaining more than recommended with the median birth weight infant), the odds of their children being overweight at age 3 years is 4-fold greater that for the reference women. Being overweight in early pregnancy (BMI = 27) and gaining within the range (net gain of 15 pounds) was not associated with increased risk of overweight in children, but gaining more than recommended (net gain of 20 pounds) increased the risk of overweight
Table 3 Illustrations of childhood risk of overweight by maternal BMI and net gestational weight gain (Net GWG)
* Ref is the reference category for the value immediate below it Note: Ref: Reference category to which other values in column are compared. Values derived using equation in Methods section of paper
among offspring by 2.5-fold. Being obese in early pregnancy (BMI = 31), was associated with increased risk of overweight in offspring at both the 15 and 20 pounds of net gestational weight gain (column 1, Table 3). However, obese women who gained more than recommended in pregnancy had a 6-fold increased risk of having a child who was overweight at age 3 years compared to the normal BMI mother who gained within the recommended range. In column 2 of Table 3, we show as the reference, a woman who is overweight (BMI = 27) and if she had a median birth weight infant, one who would have gained within the IOM recommended range for pregnancy weight gain (net gestational weight gain = 15 pounds). For normal BMI women who have net gestational weight gain of 15 or 20 pounds (below or within the recommended range respectively), there is no increased risk of having an overweight child compared to the overweight reference woman. However, the normal BMI women who had net gestational weight gains of 30 pound and thus gained more than recommended, were 4 times more likely to have a child who is overweight at age 3 years than the overweight reference woman. Both being overweight (BMI = 27) and gaining more than recommended in pregnancy (net gestational weight gain = 20 pounds) and being obese (BMI = 31) and gaining within the range (net gestational weight gain = 15), increased the odds of overweight among children by 2-fold. Being obese and gaining more weight than recommended in pregnancy (net gestational weight gain = 20 pounds) increased the odds of overweight at age 3 years in offspring more than 5-fold compared to the overweight mother (BMI = 27) who had a net gestational weight gain within the recommended range. In column 3 of Table 3, we show the odds ratio of gaining more than recommended for each maternal BMI group with women who gained within the range in that BMI group as the reference. Excess gestational weight gain is associated with an increasing risk of being overweight in childhood as maternal BMI increases, from 2.060 in normal BMI women to 2.617 in obese women.
Hypothetical women
Odds ratios for childhood overweight at 3 years (BMI [85th BMI percentile)
BMI
Net GWG(lb)
Column 1
23
15
0.485
0.457
23
20
1 (Ref)
0.941
23
25
2.060
1.939
1 (Ref)
23
30
4.245
3.994
2.060
27
15
1.063
1 (Ref)
1 (Ref)
27
20
2.468
2.322
2.322
31
15
2.326
2.189
1 (Ref)
31
20
6.089
5.730
2.617
Column 2
Column 3*
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Discussion Higher maternal early pregnancy BMI was associated with increased likelihood that the offspring would be overweight at age 3 years. For each 1 unit increase in maternal BMI, there was about a 10% increase in the risk of overweight in the children. We found a significant interaction between maternal BMI and net gestational weight gain while controlling for other potential confounders. Maternal BMI modified the effect of a given amount of net gestational weight gain on the risk of overweight in offspring at age 3 years. The results of this study support the earlier findings of Whitaker [7] and Salsberry and Regan [8] on a positive relationship between maternal BMI and overweight risk in offspring, as well as, more recent findings of Li and colleagues [22] on early and late onset overweight. We did not replicate Oken et al.’s [9] finding, from a contemporary Boston cohort of pregnant women, of an independent effect of excessive gestational weight gain on risk of overweight in offspring. Recently Wrotniak and colleagues [23] found that the odds of overweight (BMI [95th percentile) in offspring at age 7 years increased 3% for every kg of gestational weight gain in participants in an older data set from the 1959–1972 National Collaborative Perinatal Project. In this data set in which only 11% of women gained excessively, excessive gestational weight gain increased the risk of overweight in offspring by 48%. The results of the multivariable analyses provide insight into the clinical impact of gaining more weight than is recommended during pregnancy for one’s BMI group. For example, a normal BMI mother with an early pregnancy BMI of 23 who gains more weight than recommended (net gestational weight gain = 30 pounds), the risk of having an overweight child is increased 4-fold compared to an overweight mother (BMI = 27) whose weight gain in pregnancy is within the recommended range. For the obese mother (BMI = 31), excessive gestational weight gain (net gestational weight gain = 20 pounds) increases the risk of childhood overweight nearly 6-fold compared to the overweight mother who gains within the recommended range. The meaning of an absolute number of pounds of gestational weight gain differs by maternal pre-pregnancy BMI when it comes to childhood weight as an outcome just as it does for infant birth weight. The results on the confounding variables included in the logistic models are mostly consistent with the literature. Smoking during pregnancy was associated with a 3-fold increase in risk of overweight in childhood in our study. In a systematic review of the literature, Huang, Lee, and Lu [24] found prenatal exposure to maternal smoking increased the odds of obesity in childhood to 1.5–2.0. Oken, Levitan, and Gillman found a similar value in a
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recent meta-analysis [25]. Leary and colleagues [26] recently showed that the elevated BMI of children exposed prenatally to maternal smoking is due primarily to elevated fat mass, but some increase in lean mass is also present. Our finding of higher birth weight associated with increased risk of overweight is consistent with the literature [5, 7, 8, 22]. Unlike most meta-analyses and reviews of the literature, we did not find a protective effect of exclusive breastfeeding for 6 months or more [27, 28]. We do not think that our result is due to the small number of children who were exclusively breastfed for this time period (N = 42; 22.6% of the sample). We are inclined to suggest that many factors are associated with childhood overweight and obesity and some are more important than others in some subgroups of the population [29, 30]. In the rural population included in this study, breastfeeding was not protective against childhood overweight. We undertook this study with the data available because we knew we had very good measures of maternal BMI, weight gain in pregnancy and other potential confounding variables. Our next step is to audit the medical records for the entire cohort and collect additional information on the infants and further examine the models presented here. This is important because the current study has several limitations: First, our sample size, while large enough to detect some effects of maternal weight characteristics on children’s risk of overweight, is limiting in terms of the complexity of the models that can be tested. Second, with a small sample size there is the danger that a few influential cases could be driving some of the relationships reported here. We were particularly concerned about small sample size effects related to net gestational weight gain in the obese women (N = 48). In subgroup analyses (data now shown), this is the only subgroup of women in which net gestational weight gain is an independent predictor (P = 0.05) of overweight in children. Removal of two influential cases with BMI in the mid-40 s and negative net gestational weight gains changes the odds ratio from 1.070 to 1.052 and increases the p-value to 0.175. None of the children born to obese women who had negative net gestational weight gain were overweight at age 3 years, while 90% of the children whose mothers had a net gestational weight gain of 25 pounds or more were overweight at age 3 years. Thus we believe the relationship between maternal net gestational weight gain and child overweight is real, but it merits further examination in a larger sample with more complex statistical models. Such research may also help to elucidate potential mechanisms for the relationship between maternal weight characteristics and child overweight. The magnitude of the childhood obesity epidemic calls for multiple interventions on many fronts. An implication
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of this study is that maternal weight characteristics in pregnancy cannot be ignored in addressing the epidemic. Oken [31] points out the complexity of the pathways linking maternal weight and weight gain with child outcomes, in a recent workshop report from the National Research Council and the Institute of Medicine. She states that clarifying how these variables interact will aid in understanding where a greater impact can be achieved with intervention. The three most often mentioned potential mechanisms or pathways include intrauterine programming of hormonal mediators, genetics, and shared environmental factors such as dietary patterns and physical activity. It is not possible specify which of these is more important based on the results of this study. The American College of Obstetricians and Gynecologists recommends that obese women should undertake a weight reduction program before pregnancy [32]. This is a laudable goal, but will not be realistic for all women. Intervention during pregnancy is also a possibility that has shown some success. Two teams of investigators have demonstrated that it is possible to reduce the prevalence of excessive gestational weight gain through clinical and patient education interventions [16, 17]. Recently two other teams have shown this to be possible in obese women [33, 34]. The results presented in this paper suggest that interventions to reduce maternal weight in the preconception period and to reduce excessive weight gain during pregnancy have the potential to play an important role in preventing childhood obesity. In conclusion, maternal early pregnancy BMI is a significant and important influence on risk of overweight in children during the preschool years. Higher levels of net gestational weight gain increase the risk of overweight in childhood, especially among the offspring of high and obese BMI women. Nevertheless, gaining more weight in pregnancy than is recommended by the IOM is related to an increased risk of overweight among children of women with normal, high and obese pre-pregnancy BMI. Interventions to reduce maternal pre-pregnancy BMI in overweight women and excessive gestational weight gain should be part of the various approaches to addressing childhood obesity. Acknowledgements The funding for the collection of the data for the Bassett Mothers Health Project was provided by the National Institute of Child Health and Human Development (Grant No. HD 29549). The audit of the children’s medical records was conducted by Lydia Gedmintas at Bassett Healthcare.
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