Early onset childhood obesity is one of the leading pediatric health concerns in the United States.1 Children who are obese before the age of 5 years are more likely to be obese as adults, and the obesity is often more severe if it starts before the age of 5 years. The etiology of childhood obesity is multifactorial. However, there are several known risk factors for early onset childhood obesity. Several of these risk factors occur before or immediately after the child is born. As maternity care providers, we can help mothers decrease the risk of early onset childhood obesity by educating pregnant women about these known risk factors. These risk factors are maternal obesity at the time of pregnancy; excessive weight gain during pregnancy; smoking before, during, and/or after pregnancy; and bottle-feeding the infant after birth.

Maternal obesity at the time of pregnancy is a challenging risk factor to address. In a large study by Whitaker2 (N = 8494), it was noted that by 4 years of age, 24.1% of children were obese if their mother was obese during the first trimester of the pregnancy compared with only 9% of children whose mother was of normal weight during the first trimester of pregnancy. When the investigators controlled for maternal race, education, age, marital status, weight gain, and smoking in the mother and birth weight, birth year, and gender in the children, the children with obese mothers were still at a greater risk for early onset obesity. The relative risk of obesity was noted early on as children were 2 times more likely to be obese at the age of 3 years, and 2.3 times more likely to be obese at the age of 4 years if the mother was obese during the first trimester of pregnancy.2 In addition, in another study, Hispanic children and non-Hispanic white populations children were 1.5 times more likely to be overweight or obese during the preschool years if their mother was overweight or obese during the first trimester of pregnancy.3

Addressing maternal weight at the time of pregnancy represents a lost opportunity. Ideally, women would be seeking preconceptual counseling or the topic of prepregnant weight status would be discussed in primary care visits, offering women the opportunity to consider the potential implications of obesity should they become pregnant. Healthcare providers can offer counseling, education, and resources to support weight loss for women who are obese as a component of their regular healthcare visit. There is a fine line between creating an atmosphere of support and education and the risk of creating a sense of blame or shame for women who are obese when they present to prenatal care. At the point of pregnancy, a shift in focus should occur to address other risk factors instead of returning to what can no longer be changed once she is pregnant. That does not ignore that her longer-term health will be improved by maintaining a healthy weight postpartum, but the emphasis for counseling can be reframed to address aspects of health she can address without creating a sense of loss or fear regarding the factors that she can no longer change.

Once a woman is pregnant, the focus for maternity care providers can turn to the issue of maternal weight gain during pregnancy. There is an association between the amount of weight an obese mother gains during pregnancy and early onset childhood obesity. A child whose mother was obese and gained more than the recommended amount of weight during pregnancy had a 6-fold increased risk of being overweight or obese during the preschool years. However, there was no significant relationship between maternal weight gain and childhood overweight or obesity for mothers who had a normal body mass index at the time of pregnancy.4 Not only can maternal weight gain during pregnancy affect a preschool-aged child's risk of being overweight or obese, it can affect school-aged children. An obese mother who gains more than the World Health Organization recommendation of 11 to 20 lb during pregnancy had a 48% increased risk of having a child who was overweight or obese at the age of 7 years than mothers who gained only the recommended weight level of the World Health Organization.5

A mother who is obese at the time of pregnancy would benefit from ongoing nutritional support during her prenatal visits as well as in between the visits. Mothers who are obese at the time of pregnancy may benefit from a referral to a nutritionist. The nutritionist could provide assistance to help the mother develop a dietary plan for pregnancy. Working with a nutritionist may help the mother change current dietary practices, which would be beneficial to the mother and the unborn child. In addition, these changes may persist after delivery and be beneficial to both the mother and the child. If a practice has a large number of mothers who are obese, a nutritional support group that meets once a month at the office may be beneficial to the mothers. In addition, to help decrease the risk of excessive weight during pregnancy, obese mothers should be encouraged to participate in an exercise program that is safe for her and her unborn child.

Finally, maternal smoking before, during, or after pregnancy has been shown to be a risk factor for early onset childhood obesity. Children who were exposed to smoke in utero were more likely to be obese than those who were not exposed to smoke in utero.6 In addition, it has been found in several studies that smoking during the prenatal period is associated not only with overweight and obesity but also with shortened stature in children.7 Similar to the issue of maternal obesity prior to pregnancy, the ideal would be to address the risks of smoking and obesity in children preconceptually; but as it is well known, only about half of pregnancies are planned, so the opportunity for risk reduction preconceptually is limited but can be addressed through information campaigns about the risks of smoking generally when women are seeking primary healthcare services.

Once a woman is pregnant, there remain opportunities to address the risk of childhood obesity by stopping smoking once she initiates prenatal care. Exposure to smoke throughout pregnancy poses a greater risk for early onset overweight and obesity in children than smoking only in the early stages of pregnancy. Addressing cessation of smoking from the initiation of prenatal care and during each subsequent visit provides an opportunity to support a woman to stop or at least reduce the amount she is smoking during pregnancy. The risks of smoking during pregnancy are well documented,6-9 but women may not always understand the long-term implications for aspects as obesity. Providing this information, along with resources to support cessation, is an ongoing preventive health approach for childhood obesity and improved maternal health in general.

Finally, breast-feeding has been shown to be protective against early onset obesity in children. With all the health benefits documented for breast-feeding, both the American Academy of Pediatrics and the World Health Organization have stated that breast-feeding is best for an infant and the infant needs nothing besides breast milk for the first 6 months of life. The effects of bottle-feeding can be seen early on in life. Infants who were bottle-fed were shown to have higher weights as early as 3 months of life than infants who were being breast-fed.10 Infants who were bottle-fed were shown to be at 3 times greater risk of rapid weight gain during the first 3 years of life than those who were breast-fed.11 In 1 study of bottle-fed children, the rate of overweight or obesity by 4 years of age was double that of infants who were breast-fed and that rate tripled by the age of 6 years.10 Breast-feeding has also been shown to be protective against childhood obesity even if there are other maternal risk factors for early-onset childhood obesity. In 1 study, breast-feeding was inversely associated with early-onset childhood obesity after controlling for maternal diabetes and maternal weight status. Finally, the relationship between bottle-feeding and early-onset childhood obesity was found to remain significant even after controlling for parental education, parental obesity, maternal smoking, high birth weight, daily television watching greater than 1 hour per day, having siblings, and physical activity.12 In addition to the benefits to the infant, breast-feeding provides a significant benefit for the mother. Exclusively breast-feeding for the first 6 months of the infant's life has been shown to help mother lose weight during the postpartum period.13

During the course of prenatal care, the opportunity to address the benefits of breast-feeding is abundant. From entry into prenatal care, the healthcare provider can assess the woman's desires for feed method and can offer ongoing education and information about the many benefits that have been identified for breast-feeding including the reduced risk of childhood obesity. The decision to breast-feed or not is not as direct, nor as simple as the desire to reduce health risks for the baby, however, and is steeped in cultural and social messaging about the women's bodies generally and specifically the sexualized nature of breasts. Assessing women's comfort with these issues throughout the process of prenatal care and working with her to determine whether these represent barriers or not can be an important aspect of supporting her to potentially select to breast-feed.

In the process of providing counseling and education to women about the health risks and prevention opportunities related to childhood obesity, it is important to note that while recent studies have shown relationships between maternal smoking, obesity at the time of pregnancy, and bottle-feeding and early-onset childhood obesity, these are only relationships and should not be thought of as cause and effect. As healthcare providers, we have to be able to walk that fine line between helping mothers understand the maternal factors associated with early onset obesity, but do so in a way that does not blame the mother or create a sense of shame that limits her comfort to work with her healthcare provider. It is also critical to not just focus on the health advantage of addressing the risks of childhood obesity but to instead frame the focus on the overall health and well-being of the mother. The paradox of pregnancy is that for many women, it represents a time when their motivation may be high to change behaviors or improve their health status for the sake of their growing baby instead of valuing the benefits they will have themselves as a result of those changes. Maternity care providers have an excellent opportunity to support the positive health changes women may seek initially because of their pregnancy but they can also highlight the benefits for the woman directly over her life span.

Obesity is a complex health challenge for maternity care providers to address. Prenatal care represents a unique opportunity to support lifelong healthy lifestyle changes for women. It also promotes optimal opportunities for children to avoid the risks of obesity and other health concerns by addressing maternal weight gain during pregnancy, smoking cessation, and breast-feeding to promote improved health for both mothers and their children.

-Nicole Boucher, PhD, MS, CPNP

Clinical Instructor

University of Michigan

400 North Ingalls, Ann Arbor, MI 48109

([email protected]).

-Lisa Kane Low, PhD, CNM, FACNM

Associate Professor

University of Michigan

400 North Ingalls, Ann Arbor, MI 48109

[email protected]

References