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Journal of Obesity
Volume 2012, Artile !" #$%1%&, '
pages doi(10)11$$*2012*#$%1%&
Research Article
Maternal and Early Childhood Risk Factors for Overweight
and Obesity among Low-Income Predominantly lack
Children at !ge Five "ears# ! Pros$ective Cohort %t&dy
'aveed (afar )an*&a+
,+ -+ .
&shra Mahmood+
/
M0 !min&l Islam+
,
and Robert L0 1oldenberg
2
1
Department of Epidemiology, School of Public Health, University of Alabama at irmingham, irmingham, A! "#$%&, USA
$
'ommunicable Disease Prevention and 'ontrol Services, ritish 'olumbia 'entre for Disease 'ontrol, (## )est 1$th Avenue,
*ancouver, ', 'anada *#+ &R&
"
School of Population and Public Health, University of ritish 'olumbia, *ancouver, ', 'anada *(, 1+"
&
R,- -nternational, Research ,riangle Par., /' $001%, USA
#
Department of 2bstetrics and 3ynecology, 'olumbia University, /e4 5or., /5 111"$, USA
Correspondene should be addressed to +a,eed -afar Jan.ua, na,eed).an.ua/bd)a
0eei,ed 2% June 20121 Aepted 2% August 2012
Aademi 2ditor( "a,id Allison
Copyright 3 2012 +a,eed -afar Jan.ua et al) 4his is an open aess artile distributed under the Creati,e Commons Attribution
5iense, whih permits unrestrited use, distribution, and reprodution in any medium, pro,ided the original wor6 is properly
ited)
2b6ective) 4o identify maternal and early hildhood ris6 fators for obesity and o,erweight among hildren at age $ in the state of
Alabama) 7ethods) 7e reruited %#0 mothers during early pregnany from 8ni,ersity of Alabama Prenatal Clinis in a prospeti,e
ohort study and followed them throughout pregnany) 7e followed their hildren from birth until $ years of age) 4he main outome
measure was obesity 9:;! for age and se< '$th perentile= at $ years of age) 7e used poisson regression with robust ,ariane
estimation to ompute ris6 ratio 900=) Results) At the $th year of followup, %1 9')>?= of the hildren were obese and @$ 911)$?= were
o,erweight 9:;! @$thA<'$th perentile=) !n multi,ariable analysis, maternal prepregnany o,erweight 900( 2)&0, '$? C!( 1)2'A
#)11= and obesity 900( 2)$&, '$? C!( 1)#'A#)&1=, and hildBs birth weight >@$th perentile 900( 2)0#, '$? C!( 1)1&A &)>@= were
assoiated with hildhood obesity) ;aternal prepregnany :;!, birth weight, and maternal smo6ing were assoiated with the hild
being o,erweight 1A12 igarettes*day ,ersus 0 igarettes*day 900( 1)#0, '$? C!( 1)02A1)'1=) 'onclusion) Children of o,erweight and
obese mothers, and hildren with higher birth weight, are more li6ely to be obese and o,erweight at age $) ;aternal smo6ing 1A12
igarettes per day is assoiated with the hild being o,erweight)
,0 Introd&ction
Obesity has reahed epidemi proportions in the 8nited Ctates
98C= where, in 200%D0@, &#? of adults were obese and >@?
were o,erweight E1F) 4he situation is worse in some southern
states li6e 5ouisiana, ;ississippi, and Alabama where almost
1 person out of & is obese or o,erweight) ObeDsity is
partiularly more ommon in the AfrianDAmerian population
9##?= than in their white ounterparts 9&&?= E1F) !n 200%D0@,
among hildren 2 to $ years of age, 11? of AfrianDAmerians
ompared to $)$? of 7hites were obese and 2>? ,ersus '?
were o,erweight E2F) Compliations
of obesity are also more se,ere among AfrianDAmerians E&,
#F) 4he inreasing pre,alene of obesity and o,erweight has
important health and eonomi impliations E$, >F) !f urrent
trends ontinue, the higher pre,alene of obesity may result in
a deline in life e<petany in the 8nited Ctates E&, #F) 4his
inrease in mortality ris6 arises from a higher ris6 of many
omorbidities, inluding type 2 diabetes, hypertension,
hyperholesterolemia, osteoarthritis, gallbladder disease, and
some aners E%F) Obesity an also produe psyhologial
morbidity, espeially among women and hildren E@F) A study
fousing on the burden of obesity in the 8C has re,ealed that
relati,e to normalDweight men and women,
2
o,erweight men and women lost 2%0,000 and 1)@ million
Guality ad.usted life years in the year 2000, respeti,ely)
Obese men and women lost 1)' million and &)# million GuaD
lityDad.usted life years in the year 2000, respeti,ely E#F)
Ce,eral studies ha,e reported that early hildhood obesity
predits later obesity in adulthood1 hene pre,enti,e meaDsures
should start early during hildhood E'A12F) Ctudies ha,e
indiated that hildhood obesity is assoiated with the
de,elopment of noninsulinDdependent diabetes at an early age)
!n addition to ad,erse physial health, obese hildren are more
li6ely to suer mental health issues and psyhosoial
problems and e,en disrimination E@F)
Cine treatment and management of obesity is diult and
hildhood obesity persists during adulthood, determinDing
perinatal, and early hildhood ris6 fators pro,ides an a,enue
for early inter,entions) Ce,eral studies ha,e assessed the
fators that predit hildhood obesity) ;aternal prepregDnany
:;!, weight gain during pregnany, smo6ing during
pregnany, low soioeonomi status, birth weight, inreased
weight gain during early years, and poor home en,ironment
ha,e been reported to predit early hildhood obesity E2, $, %,
1&A1$F) Howe,er, most of studies in the 8nited Ctates ha,e
assessed the prepregnany and early hildhood ris6 fators
among predominantly white populations E1>, 1%F largely
ignoring the AfrianDAmerian and Hispani populations E1@A
21F) 7e assessed maternal and early hildhood ris6 faDtors for
being obese at $ years of age for a lowDinome preDdominantly
AfrianDAmerian ohort)
-0 Methods
$818 Study Design and Population8 "ata for this study ame
from a longitudinal study of pregnany outomes and
hildhood psyhomotor de,elopment at the age of $ years)
"etails of population and measurements ha,e been reported
pre,iously E22, 2&F) 4he mothers of hildren were reruited
from a population of lowDinome women see6ing prenatal
are through the publi health system in :irmingham,
Alabama from "eember 1'@$ to Otober 1'@@) !n this
population, <$? of the women breastDfed their infants and
,irtually all were eligible for the speial supplemental proD
gram for women, infants, and hildren 97!C=) ;others
were enrolled during early pregnany and were followed
through pregnany until deli,ery) 4heir hildren were
followed from birth until about $ years of age)
$8$8 2utcome8 4he primary outome measure in this study was
obesity among hildren at age $ years) 7e de,eloped the
outome ,ariable by employing ageD and se<Dspeifi ,alues
of :;! using the Centers for "isease Control and Pre,enD
tionBs referene growth harts for hildren and the 2<pert
CommitteeBs reommendations about hildhood obesity E2#,
2$F) Children whose ageD and se<Dspeifi :;!s were '$th
perentile at $ years of age were onsidered obese and those
with :;!s @$ and <'$th perentile were onsidered o,erD
weight E2$F)
Journal of Obesity
$8"8 Determinants8 ;ain ,ariables inluded maternal and
family attributes olleted at enrollment and during pregD
nany and hild harateristis at birth and in early hildD
hood) ;aternal data used in this analysis inluded informaD
tion regarding soiodemographi harateristis inluding,
age, rae 9bla6*white=, years of shooling, total number of
hildren in the family, total number of adults at home,
employment status of mother, and whether the family
reei,ed any 6ind of assistane from state or federal
agenies suh as 7!C or food stamps) !nformation on
mothers smo6ing status was also olleted at eah ,isit
during pregDnany) Cine there were more missing data
from the 2nd and &rd trimesters, we used 1st trimester
smo6ing status as our indiator for smo6ing during
pregnany E2>F) ;aternal prepregnany :;! was
omputed from the sub.etBs reported prepregnany weight,
and height measured at first prenatal ,isit) Prepregnany
self reported weight was highly orrelated with weight at
enrollment in first prenatal ,isit 9r = 0.'>, R
2
= 0.'2=)
Huality of the home en,ironment has been reported to
be assoiated with obesity among hildren E2%F) 7e
measured the Guality of home en,ironment using Home
Creening Huestionnaire 9HCH=) A sore of #1 and greater
reflets adeDGuate home en,ironment while less than #1
was onsidered less than adeGuate)
5ength*height and weight was measured at birth, at age
one year, and at age fi,e years)
$8&8 Statistical Analysis8 7e omputed the mean for onD
tinuous ,ariables and proportions for ategorial ,ariables
to desribe the distribution of the harateristis of study
partiipants) 7e ompared the independent ,ariables using
hiDsGuare and rossDtabulation for ategorial ,ariables
and tDtest or A+OVA or nonparametri for ontinuous
,ariables, whihe,er was appropriate)
;aternal prepregnany :;! was ategoriIed into low and
normal 9<1@)$A2#)'=, o,erweight 92$)0A2')'= and obese
9&0)0=) ;aternal smo6ing, measured as number of igaDrettes
smo6ed during the 1st trimester, was ategoriIed into highD
freGueny smo6ers who smo6ed 1& igarette per day 9@$th
perentile=, smo6ers with some degree of smo6ing 91A12
igarettes per day=, and nonsmo6ers) Age was ateDgoriIed
into <20 and 20 years, eduation into <12 grades and 12
grades, HCH sores into <#1 and #1, and the number of
hildren at home was dihotomiIed at the median into 2 and
>2) :irth weight was analyIed as a ontinuous ,ariable and
then ategoriIed based on gestational age and raeDspeifi
perentiles for the 8nited Ctates population as @$th perentile
and >@$th perentile E2@F)
7e omputed ris6 ratios 900= to estimate the assoiation
of ris6 fators with outomes) 4wo approahes ha,e been
proposed to ompute ris6 ratio in prospeti,e studies with
ommon outomes1 log binomial regression and poisson
regression with robust ,ariane estimation E1$, 2'F) 7hen
outomes are ommon, the odds ratio pro,ides inflated estiD
mates of assoiation) Cometimes log binomial regression
models do not on,erge) 7e also e<periened the same probD
lem) 4hus, we used poisson regression with robust ,ariane
Journal of Obesity
estimation to ompute rude and ad.usted 00s and '$?
onfidene inter,als implemented through Pro J2+;O"
in CAC E&0F) !nteration of prepregnany :;! and birth
weight was not signifiant) 7e also identified determinants
of o,erweight using the same approah as outlined for
obesity) 7e onduted all analyses using CAC ,ersion ')2)
.0 Res<s
7e had data for %#0 singleton births with the infants folDlowed
to an a,erage age of $)# years) After e<lusion of ases with
missing information about the ,ariables used in the analyses,
data for >#' sub.ets were a,ailable that ontriDbuted to the
final model) 7e ompared the proportion of o,erweight
hildren between partiipants inluded in final model and
those who ould not be inluded beause of missDing
information) 7e found no signifiant dierenes betDween
partiipants who were inluded in the final model 9n = >$*>#',
10)2?= ,ersus those who were not inluded in the model 9n =
>*'1, >)>?, P = 0.&=)
"818 'haracteristics of the Study Sample8 AfrianD
Amerians onstituted the ma.ority of the sample 9%%?=)
;ost of the births ourred at term 9%'?=) 4he mean birth
weight was 2@'2)> >#1)' g with a median of 2@#$ g
9range( >#0A $1%$ g=) 4he proportion of low birth weight
95:7= was 2#? and >)%? were abo,e the @$th perentile
of birth weights in the 8nited Ctates 94able 1=) ;ean age of
the mother at the time of deli,ery was 2# years) Ci<tyDsi<
perent of the mothers had at least a 12th grade eduation,
>1? were employed, &#? were on wellfare, 1%)$? were
enrolled in 7!C, and $')2? reei,ed food stamps) 4he
mean number of hildren at home was 2)%) 4he mean 9C"=
and median ErangeF prepregnany :;! was 2#)$9%)1=
6g*m
2
, 22)$ E1&A$0F, and 1%)@? of the mothers were obese
9:;! &0= before pregnany) 4he mean 9C"= and median
ErangeF number of igarettes smo6ed during the 1st
trimester were $)# 9')$= and 0 E0A>&F1 >1)#? did not
smo6e, and 1$)&? smo6ed 1& igarettes per day 94able 1=)
"8$8 2ver4eight and 2besity8 At the $th year of followDup
,isit, ')>? of the hildren were obese aording to their
ageD and se<Dspeifi :;! using the '$th perentile as the
referene definition of obesity E2#, 2$F) At the same ,isit,
11)$? hildren were o,erweight 9:;! @$thA<'$th perD
entile= 94able 1=)
4hose hildren who had higher birth weight 9P = 0.001= or
higher weight at 1)2 years of age 9P = 0.002= were more li6ely
to be obese at the $th year of followup) Jirls were more li6ely
to be obese than boys 9>0)1? ,ersus &')#?, P = 0.0#1=) Obese
mothers were 2)' times more li6ely to ha,e obese hildren 9P
< 0.001=) Children of mothers who had <12th grade eduation
were also more li6ely to be obese as ompared to those who
ompleted 12th grade 900( 1)>%, '$? C!( 0)''A2)@&=) Ha,ing
two or less hildren at home was also assoiated with
inreased obesity 9P = 0.00%=) 2mployDment status of the
mother, use of food stamps, 7!C, materDnal age, fatherBs
eduation, rae*ethniity, Guality of home
&
en,ironment, and number of adults at home were not signiD
fiantly assoiated with obesity 94able 2=)
;ultiple poisson regression models with robust
,ariane estimation for ris6 fators assoiated with obesity
re,ealed that hildren of mothers who were o,erweight
900( 2)&0, '$? C!( 1)2'A#)11= or obese before pregnany
900( 2)$&, '$? C!( 1)#'A#)&1= were more li6ely to be
obese) KurtherDmore, hildren who were abo,e the @$th
perentile of birth weight were also more li6ely to be obese
at age fi,e 900( 2)0#, '$? C!( 1)1&A&)>@=) Ha,ing two or
less hildren at home 900( 1)>#, '$? C!( 1)01A2)>#= and
being a female hild 900( 1)>%, '$? C!( 1)0@A2)%2= were
also assoiated with being obese) Children of mothers
smo6ing 1A12 igarettes*day during the 1st trimester were
more li6ely to be obese as ompared to those who did not
smo6e 900( 1)#2, '$? C!( 0)@@2)&0= while if mothers
smo6ed 1& igarettes their hildren were less li6ely to be
obese 900( 0)$&, '$? C!( 0)22A1)2%=) +either relationship
was statistially signifiant 94able &=)
4he multi,ariable model for determinants of being
o,erDweight at age $ showed similar results 94able #=) !n
the model for hildhood o,erweight, the mother being
o,erweight or obese before pregnany, birth weight >@$th
perentile, and mother smo6ing 1A12 igarettes*day were
eah assoiated with being o,erweight) Children of mothers
smo6ing 1A12 igarettes*day during the 1st trimester were
more li6ely to be o,erweight as ompared to those who did
not smo6e 900( 1)#0, '$? C!( 1)02A1)'1=)
/0 3isc&ssion
!n this study of a predominantly AfrianDAmerian popuD
lation, we found that high prepregnany :;!, high birth
weight, fewer number of hildren at home, female se< of the
hild, and mothers smo6ing 1A12 igarettes*day during the 1st
trimester were assoiated with being both o,erweight and
obese at age $) Come of these fators suh as maternal
smo6ing and prepregnany :;! are modifiable and an be the
target of inter,entions) Others, li6e female gender and number
of hildren at home, are not modifiable) +onDmodifiable
fators stress the importane of understanding underlying
proesses and their ultural onte<t that put indi,iduals with
ertain attributes more at the ris6 of o,erDweight) A reent
analysis of data from the early hild are and youth
de,elopment longitudinal sample suggests that hildren with a
:;! @$th perentile are more li6ely to gain weight and reah
obese status as ompared to those who remain below $0th
perentile) Children who beome obese at an early age are
more li6ely to be obese during late hildhood and adolesene
E&>F) Hene, pre,ention of pediatri obesity early on is
important and may be ahie,ed by reogniIing and identifying
obesity at an early stage and oering ounDseling and
proati,e treatment strategies)
Assoiation of maternal prepregnany :;!
with pediDatri obesity has been reported
onsistently in both retrosDpeti,e and
prospeti,e ohorts E1%, 2%, &%F) A large retrosD
peti,e ohort study in Ohio reported inreased
odds of hildhood o,erweight with inreasing
maternal :;! during
# Journal of Obesity
4A:52 1( Charateristis of the partiipants and early hildhood determinants of obesity at the age of $ in Alabama 9n = %#0=)
Variables n ? ;ean C" ;edian ErangeF
;aternal harateristis
0ae
:la6 $%0 %%)0
7hite 1%0 2&)0
;other age at deli,ery 9years=
;ean 9C"= 2#)0 9#)>= 2& E1#A#&F
<20 11@ 1>)0
20A2' $&# %2)2
>2' @@ 11)@'
;otherBs mean 9C"= years of shooling 11)@ 92)2= 12 E0A1@F
;other ompleted 12th grade #@% >>)2
2mployed, ? &%# >1)1
8sing food stamps, ? &%0 $')2
On welfare, ? 1'1 &#)0
Parity, mean 9C"= 1)& 90)@= 1 E0A'F
Prepregnany :;!, mean 9C"= 2#)$ 9%)1= 22)$ E1&A$0F
:;! groups
5ow 9<1@)$= 100 1#)%
+ormal 91@)$A2#)'= &#' $1)2
O,erweight 92$A2')'= 111 1>)&
Obese 9&0= 121 1%)@
+umber of igarettes smo6ed during 1st trimester $)# 9')$= 0 E0A>&F
0 igarette #$# >1)#
1A12 igarette 9>1A@$th perentile= 1%' 2#)2
1& igarette 9>@$th perentile= 10% 1$)&
Alohol inta6e during pregnany, ? 1@> &1)'
Child harateristis
Ce<, ? female &>2 #@)'
:irth weight 9grams=
;ean 9C"= 2@'2)> 9>#2)0= 2@#$ E>#0A$1%0F
<2$00 1%> 2&)@
2$00A2''' 2$1 &&)'
&000A&'00 2@$ &@)$
#000 2@ &)@
Abo,e @$th perentile $0 >)%
Preterm, ? 1#' 20)1
:;! at age $ years
+ormal weight 9<@$th perentile = $@# %@)'
O,erweight 9@$th to <'$th = @$ 11)$
Obese 9'$th perentile= %1 ')>
the first trimester of pregnany E1%F) ;aternal prepregnany
:;! has also been reported as a ris6 fator for adiposity in
AfrianDAmerian hildren in Philadelphia E1@F) ;any
mehanisms ha,e been proposed for maternal obesity leadDing
to hildhood obesity inluding inheritane of genes that
enhane suseptibility, E1&, &@F feeding and eating beha,iors1
obese mothers may ha,e poor eating habits, whih may
negati,ely impat the intrauterine en,ironment E&'F) 4hese
findings emphasiIe the importane of hildhood obesity preD
,ention ,ery early on or e,en before the start of pregnany)
!n this study, being a female hild was
assoiated with a higher ris6 of obesity) Among
AfrianDAmerian hildren and adolesents, a
higher proportion of females are obese E2, >F) 4he
findings from the +ational Health and +utrition
2<amination Cur,ey 9+HA+2C=, +ational
Jrowth and Health Ctudy 9+JHC=, and many
other studies indiate that AfrianDAmerian girls
ha,e higher :;!s than white girls of similar ages
E2, #0A#2F) Cultural attitudes about body image
among AfrianDAmerian ommunities indiate
that AfrianDAmerians are relati,ely more
tolerant of a large
Journal of Obesity $
4A:52 2( Crude ris6 ratio and '$? C! of prepregnany and early hildhood fators assoiated with being obese 9 '$th perentile= at the
age of $)
Variable
Obese
00 '$? C!
N n ? P
Child harateristis
Ce<
;ale &%@ 2@ %)# 1)00
Kemale &>2 #& 11)' 0)0#1 1)>0 91)02A2)$2=
:irth weight 9Lg=
based on gestational age and rae speifi birth weight perentiles for 8C population)
> Journal of Obesity
4A:52 &( ;ulti,ariable model showing ad.usted ris6 ratio for
materDnal and early hildhood determinants of obesity 9'$th
perentile= at the age of $ in Alabama n = >%@
)
Variables
Ad.usted 00
P
9'$? C!=
;aternal prepregnany :;!
+ormal and low 9<2#)'= 1)00
O,erweight 92$A2')'= 2)& 91)2'A#)11= 0)00$
Obese 9>&0= 2)$& 91)#'A#)&1= <0)001
:irth weight 9Lg=
0 igarette 1)00
1A12 igarette 9>1A@$th perentile= 1)#2 90)@@A2)&= 0)1$2
1& igarette 9>@$th perentile= 0)$& 90)22A1)2%= 0)1$#
C!( onfidene inter,al)
Ad.usted ris6 ratio omputed using poisson regression model with robust
,ariane estimation)
:ased on gestational age and rae speifi birth weight perentiles for
8C population)
)
Variables
Ad.usted 00
P
9'$? C!=
;aternal prepregnany :;!
+ormal and low 9<2#)'= 1)00
O,erweight 92$A2')'= 1)'91)&#A2)%= <0)001
Obese 9>&0= 1)@@91)&&A2)>$= <0)001
:irth weight 9Lg=
@$th perentile
>@$th perentile 1)'#91)&&A2)@&= <0)001
Ce<
;ale 1)00
Kemale 1)2% 90)'>A1)%= 0)0''
Cmo6ing during 1st trimester
0 igarette 1)00
1A12 igarette 9>1A@$th perentile= 1)#091)02A1)'1= 0)0&$
1& igarette 9>@$th perentile= 0)'@90)>&A1)$#= 0)'&%
C!( onfidene inter,al)
Ad.usted ris6 ratio omputed using poisson regression model with robust
,ariane estimation)
:ased on gestational age and rae speifi birth weight perentiles for
8C population)