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DOI: 10.1097/JPN.

0000000000000005

SPECIAL EDITORIAL
Nicole Boucher, PhD, MS, CPNP; Lisa Kane Low, PhD, CNM, FACNM

Prevention of Childhood Obesity Risk


From a Pre-Conceptual and Pregnancy
Care Perspective
arly 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

Disclosure: The authors have disclosed that they have no significant


relationships with, or financial interest in, any commercial companies
pertaining to this article.

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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
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affect a preschool-aged childs 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,69
The Journal of Perinatal & Neonatal Nursing

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 bottlefeeding 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 breastfed.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 earlyonset 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 infants 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 womans desires for feed method and
can offer ongoing education and information about
the many benefits that have been identified for breastfeeding 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 womens bodies generally and
specifically the sexualized nature of breasts. Assessing
womens 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.
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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 breastfeeding 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
(nbouche@med.umich.edu).

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Lisa Kane Low, PhD, CNM, FACNM


Associate Professor
University of Michigan
400 North Ingalls, Ann Arbor, MI 48109
kanelow@med.umich.edu

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