Running head: AN INTEGRATIVE REVIEW 1

An Integrative Review

Caroline M. Stewart

Bon Secours Memorial College of Nursing

Arlene Holowaychuk, MSN RN

Nursing Research – NUR 4122

April 10, 2018

I pledge. –Caroline Stewart

AN INTEGRATIVE REVIEW 2

Abstract

The purpose of this integrative review is to evaluate current literature pertaining to the effects of

gestational diabetes mellitus (GDM) on childhood obesity. Childhood obesity is a growing

concern globally, and determining predisposing factors for this issue could be the key to

reducing rates across the board. Due to GDM’s influence on large birth weight, researchers are

interested to determine if that influence carries on into childhood as well, potentially causing

obesity. EBSCO was utilized in searching for articles for this review. After placing limits, the

search yielded 7,480 articles. Five of these articles that best represented the aim of the PICOT

question were chosen by the researcher. No correlation was found to exist between GDM status

and childhood obesity in offspring. A correlation was, however, found between maternal pre-

pregnancy body mass index (BMI) and future occurrences of childhood obesity. Several

limitations to this review must be mentioned including the review only examining five articles

and the researcher having little experience completing integrative reviews. Limitations of the

studies reviewed included lack of diversity in the selected sample and collecting data in ways

that allowed for bias. The findings discussed in this review should encourage healthcare

professionals to educate women about the importance of maintaining a healthy body weight and

the potential effects related to uncontrolled GDM. Further research should include larger sample

sizes, longer duration, and additional follow-up studies to determine long-term effects.
AN INTEGRATIVE REVIEW 3

An Integrative Review

Childhood obesity is a growing concern both in the United States and abroad.

Recognizing risk and predisposing factors is the first step in decreasing and preventing this

growing epidemic. It is suspected that exposure to high levels of glucose in utero may place

offspring at a greater risk for developing obesity during childhood. The aim of this integrative

review is to collate literature pertaining to the researcher’s PICO question, are children (ages 2-

11) born to mothers with gestational diabetes at increased risk for childhood obesity compared

with children born to mothers without gestational diabetes? Until recent years, research

regarding this topic has been limited. However, researchers are becoming increasingly interested

in the potential link between gestational diabetes and childhood obesity, therefore more studies

are being conducted. What is currently known about this topic is that gestational diabetes has a

direct effect on birth weight and mothers with GDM often produce newborns that are large for

gestational age (LGA). The gap in knowledge and research exists due to the fact that it is

unknown if GDM influences weight and BMI during childhood as it does at time of birth. Fully

understanding if there is a correlation between GDM and childhood obesity could potentially

provide the knowledge necessary to decrease the prevalence of this growing problem.

Design and Research Methods

This integrative review is based on five articles. EBSCO is the only search engine that

was used in searching for these articles. Search word used in the search included, ‘gestational

diabetes’, ‘childhood obesity’, ‘diabetes’, ‘childhood BMI’, and ‘pregnancy’. A search via

EBSCO resulted in 7,480 articles from which the final five were chosen.

In an effort to narrow the search, a limit was set to only show articles published between

2013 and 2018. Another filter was placed for the search to only yield peer reviewed articles with
AN INTEGRATIVE REVIEW 4

a full text available. After searching under these parameters, the researcher was able to locate

five quantitative studies that relate to the PICO question. Articles were excluded if they were

published more than five years ago, not peer reviewed, or did not contain a research study

relevant to the PICO question.

Finding/Results

The findings and results of the research do not necessarily prove that there is a correlation

between GDM and childhood obesity (Landon et al., 2015; Morgan et al., 2013; Pham, Brubaker,

Pruett & Caughey, 2013; Zhao et al. 2016; Zhu et al. 2016). The review of these findings and

results is structured by the following themes: maternal GDM status, levels of maternal glycemia

during pregnancy, and treatment of GDM.

Maternal GDM Status

In three quantitative studies, researchers focused on maternal GDM status and how it

related to childhood obesity (Morgan et al., 2013; Pham et al., 2013; Zhao et al., 2016). With this

approach, researchers simply wanted to know if the mother was diagnosed with GDM or not. No

specific glucose levels were factored in to determine the severity of each individual’s GDM. In

the population based electronic cohort study by Morgan et al. (2013), 147,773 mother-child pairs

consented to participate by allowing researchers to access routinely collected healthcare data

from electronic medical records (EMR). The data collected consisted of maternal diabetes status

and offspring weight at birth and ages 1 and 5 years. The purpose of this study was to determine

if offspring weight is affected by GDM. Logistic regression models were used to examine

relationships between maternal diabetes status and offspring size. This data was adjusted to allow

for variations in maternal pre-pregnancy weight, age, and smoking status. Evidence was found
AN INTEGRATIVE REVIEW 5

linking diabetes in pregnancy to large birth weight, above the 90th percentile. However, limited

evidence was found linking diabetes in pregnancy with large weight at 1 and 5 years of age.

Similarly, the study by Pham et al. (2013), aimed to estimate whether children, aged 2-4

years, of mothers with GDM are at risk for childhood obesity. This retrospective cohort study

consisted of 2,644 women (459 in the GMD group and 2,185 in the non GDM group). This

sample greatly decreased throughout the study because researchers were only able to collect BMI

data from 255 of the 459 GDM woman toddler pairs and 1,838 of the 2,185 non GDM pairs at

the 2-4 year mark. Each participant underwent an initial exam in early pregnancy (~8 weeks

gestation) in which weight, height, and demographics were collected to calculate a BMI which

was the primary factor measured in this study. Gestational weight gain was determined by the

final data collected at 37 weeks gestation. Glucose tolerance tests were performed between 24

and 28 weeks of gestation to determine maternal GDM status. Toddler offspring BMI data was

collected 2-4 years after birth via EMR and BMIs greater than the 85th percentile were defined as

overweight and obese. Pearson [chi]2 test was used to determine categorical variables of

differences in GDM status, and Student t test was used for continuous variables. The [chi]2 test

was also used to determine differences in rates of GDM, LGA, and toddler overweight or obesity

by race or ethnicity. Multivariable logistic regression models were used to predict toddler

overweight and obesity rates and used maternal pre-pregnancy BMI as a risk factor. The study

showed that GDM was not associated with increased risk of toddler overweight and obese BMI.

However, evidence was present that related pre-pregnancy overweight and obese BMI to that of

the mothers’ offspring.

The multinational cross-sectional study, by Zhao et al. (2016), aimed to determine the

association between maternal GDM and childhood obesity at age 9-11 years in 12 countries. This
AN INTEGRATIVE REVIEW 6

study consisted of 4,740 children between the ages of 9 and 11 years. Maternal GDM status was

determined by the American Diabetes Association (ADA) or World Health Organization (WHO)

criteria. Demographics and family health history including maternal education, current maternal

BMI, maternal age at child’s birth, child age, child sex, birthweight, infant feeding mode,

gestational age and number of younger siblings were collected upon initiation of the study by a

questionnaire given to parents or guardians. Maternal GDM status was self-reported by parents

or guardians on the questionnaire. A food frequency questionnaire (FFQ) was administered to all

participants and asked about their usual consumption of 23 food categories. The FFQ allowed for

response categories including: never, less than or once per week, once per week, 2-4 days per

week, once a day every day, and more than once a day. This questionnaire was used primarily to

determine whether participants represented an unhealthy or healthy diet pattern. Physical exams

were conducted on each participant to determine height, waist circumference, weight, body fat

percentage, and maternal and childhood BMI. Multilevel linear regression models were used to

determine association between GDM and childhood BMI, waist circumference and body fat

percentage. In this study, children of GDM mothers had significantly higher mean values for

BMI, waist circumference, and body fat percentage than children of non-GDM mothers.

However, it is unclear as to whether or not these results are influenced by current maternal BMI.

Further research is needed to determine whether GDM status alone influenced childhood obesity

in this study or if current maternal BMI and other environmental factors surrounding the children

skewed the results.

Levels of Maternal Glycemia During Pregnancy

In a quantitative study by Zhu et al. (2016), researchers aimed to determine whether or

not there is a correlation between fasting plasma glucose (FPG) levels during pregnancy and
AN INTEGRATIVE REVIEW 7

offspring growth and risk of overweight and obese BMI through age 7 years. This study was a

follow-up study based on data from the Danish National Birth Cohort (DNBC), a longitudinal

nationwide study that included 101,042 pregnancies. The original data from the DNBC consisted

of sociodemographic, perinatal, and medical factors and was collected from 4 computer-assisted

telephone interviews at gestational weeks 12 and 30 and postpartum months 6 and 18. When the

children of these mothers were 7 years old, this follow-up study was conducted by sending

questionnaires online or by mail to the parents. The questionnaires asked about the child’s health

and development, including weight and height as to calculate BMI. Maternal FPG

concentrations during pregnancy were positively associated with large offspring birth size and

overweight/obese BMI at 7 years of age.

Treatment of GDM

In a quantitative follow-up study by Landon et al. (2015), researchers aimed to determine

if there is a relationship between treatment of GDM and decreased incidence of childhood

obesity. In this study, 500 participants underwent a physical exam which included height,

weight, blood pressure, and waist circumference. These participants were offspring of women

who participated in a Eunice Kennedy Shriver National Institute of Child Health and Human

Development Maternal-Fetal Medicine Units (MFMU) Network randomized clinical trial for

mild GDM. Mothers of the child participants were given a questionnaire concerning

demographic information, breastfeeding history, child health, diet, and physical activity.

Statistical analysis was completed using SAS statistical software (SAS Institute, Cary, NC).

Tests were two-tailed and P<0.05 was used to define statistical significance. At conclusion of

this study, no difference was observed in obesity rate for offspring of mothers who were treated

for GDM versus mother who were not treated.

AN INTEGRATIVE REVIEW 8

Discussion and Implications

While the results of two of the five studies discussed in this review differ slightly from

the remaining three, the consensus is that there is little to no correlation between GDM and

childhood obesity. The two articles that resulted in GDM having a correlation with childhood

obesity examined other factors such as maternal BMI that could have potentially skewed results.

Given that the majority of research proved no relationship between GDM and childhood obesity,

the PICOT question set by the researcher is supported in this review. GDM does not put

offspring at increased risk of childhood obesity.

The study by Landon et al. (2015), provided evidence that uncontrolled GDM does in fact

lead to negative outcomes in childhood such as overweight/obese BMI. The other four studies

only examined mothers with controlled GDM and their offspring’s outcomes, but this particular

study showed that there is definitely a difference in outcomes between controlled and

uncontrolled GDM.

Possessing the knowledge that controlled GDM does not have a significant correlation

with increased risk of childhood obesity when controlled appropriately allows healthcare

professionals to debunk this myth as well as to educate pregnant women diagnosed with GDM of

just how important it is to maintain tight glycemic control during pregnancy. The secondary aim

of the study by Pham et al. (2013), was to examine the potential correlation between maternal

BMI and childhood obesity. The data provided within that study proved that there is a

relationship between high maternal BMI and childhood obesity rates. Knowing this allows

healthcare professionals to educate women of the importance of maintaining a healthy body

weight and BMI to decrease risk of obesity in their offspring.

AN INTEGRATIVE REVIEW 9

Pham et al. (2013) discusses the possibility of GDM management being a modifiable risk

factor for childhood obesity. Subsequently, the researchers recommend further research to

determine whether interventions for GDM and those aimed at decreasing maternal BMI could

help to reduce childhood obesity rates. Similarly, Morgan et al. (2013) addressed how their

results warrant the need for further research to include multi-factorial parameters surrounding

maternal diabetes and offspring size. From a different perspective, Zhu et al. (2016), determined

that further research generalized to other racial and ethnic groups at high risk of GDM may be

warranted to validate their study due to the fact that their study population was composed of only

Danish-speaking participants. The researchers of this study recommend a more diverse

population for future studies. The authors also recommend longer studies with follow-up

opportunities through adolescence and adulthood of the offspring. Landon et al. (2015) also

discuss the need for larger follow-up studies in order to provide evidence of how the cycle of

GDM and obesity can be interrupted.

Limitations

Major limitations of this integrative review include the fact that it only consists of five

articles pertaining to the PICOT question at hand. A broader base of research would be beneficial

for a more diverse view on the topic of how GDM relates to childhood obesity. It should also be

mentioned that a significant amount of the articles populated through the search on EBSCO were

outside of the five year limit set for this assignment. This greatly decreased the amount of

research available for the researcher to present within this integrative review. This review was

brief as it only contained five studies, therefore it did not exhaust all potential contributing

factors of childhood obesity and they may or may not relate to GDM. The researcher compiling
AN INTEGRATIVE REVIEW 10

information for this review does not have a significant amount of experience in completing an

integrative review.

Each of the five studies presented in this review suffered from their own individual

limitations. Zhao et al. (2016) determined that one limitation of their study was simply the fact

that it is a cross-sectional study. Zhao et al. (2016) said about this limitation, “Thus, we could not

make cause-and-effect inferences.”(p. 2347) A third limitation of the study by Zhao et al. (2016),

is that maternal GDM status, current maternal body weight and height, infant feeding mode,

gestational age and child’s birth weight was self-reported by parents or guardians. This allowed

for potential bias in results. Possible the most influential limitation of this study is that maternal

GDM was diagnosed under different standards at each different site which may have greatly

skewed results.

Landon et al. (2015) discussed using BMI as the primary measure of obesity as being one

of the primary limitations of their study. Subsequently, the researchers discussed how other

measures of body composition, such as DEXA or air densitometry may have been a more

accurate way of determining obesity status within the study. Lastly, Landon et al. (2015),

discussed the fact that the participants of this study were women with only mild GDM. The

researchers went on to say that the study could have been improved by including women with

varying levels of GDM so as to demonstrate a more diverse treatment approach and the effect it

may have on obesity in offspring.

The study by Pham et al. (2013), had possibly the most devastating limitation of the five

within this review. During the study, the criteria by which GDM is diagnosed was changed from

the National Diabetes Data Group to that of Carpenter and Coustan. Another limitation of this

study is that the population is limited to only one facility. In that facility, Asian and South Asian
AN INTEGRATIVE REVIEW 11

populations are prevalent and there is an underrepresentation of the African American

population. Being that the study was limited to one facility, it also included far more individuals

who are insured with moderate to high socioeconomic status than it did uninsured individuals

with low socioeconomic status.

Morgan et al. (2013) suffered most of their limitations due to the method of data

collection. Patients’ health information was retrieved from EMR which did not allow for

explanation of any results or findings within the patient history other than what was provided in

documentation. The main issue with this is that the group labeled ‘diabetes developed post

pregnancy’ may have also included some women who truly had GDM but were misdiagnosed

during pregnancy and not definitively diagnosed until post pregnancy.

Zhu et al. (2016) suffered a limitation within their study pertaining to the method of data

collection. Due to the fact that childhood weight and height data were obtained via a

questionnaire completed by a parent or guardian, there are inevitable measurement errors.

Conclusion

Within this integrative review, the researcher was able to compile information from five

studies that all examined whether or not there is a correlation between GDM and childhood

obesity. The collective findings lead researchers to believe that there is no relationship between

maternal GDM status and subsequent childhood obesity in offspring. Some findings of the

studies reviewed suggest that pre-pregnancy maternal BMI as well as other environmental

factors could predispose children to obesity. These results directly relate to the PICOT question

by determining that there is no known correlation between GDM and childhood obesity at this

time.
AN INTEGRATIVE REVIEW 12

References

Landon, M. B., Rice, M. M., Varner, M. W., Casey, B. M., Reddy, U. M., Wapner, R. J., . . .

VanDorsten, J. P. (2015). Mild Gestational Diabetes Mellitus and Long-Term Child

Health. Diabetes Care, 38, 445-452. doi: 10.2337/dc14-2159

Morgan, K., Rahman, M., Atkinson, M., Zhou, S., Hill, R., Khanom, A., . . . Brophy, S. (2013).

Association of Diabetes in Pregnancy with Child Weight at Birth, Age 12 Months and 5

Years – A Population-Based Electronic Cohort Study. PLOS ONE, 8(11).

doi:10.1371/journal.pone.0079803

Pham, M. T., Brubaker, K., Pruett, K., & Caughey, A. B., (2013). Risk of Childhood Obesity in

the Toddler Offspring of Mothers With Gestational Diabetes. Obstetrics & Gynecology,

121(5), 976-982. doi:10.1097/aog.0b013e31828bf70d

Zhao, P., Liu, E., Qiao, Y., Katzmarzyk, P. T., Chaput, J., Fogelholm, M., . . . Hu, G. (2016).

Maternal gestational diabetes and childhood obesity at age 9-11: Results of a

multinational study. Diabetologia, 59, 2339-2348. doi: 10.1007/s00125-016-4062-9

Zhu, Y., Olsen, S. F., Mendola, P., Yeung, E. H., Vaag, A., Bowers, K., . . . Zhang, C. (2016).

Growth and obesity through the first 7y of life in association with levels of maternal

glycemia during pregnancy: A prospective cohort study. The American Journal of

Clinical Nutrition, 103, 794-800. doi: 10.3945/ajcn.115.121780

Running head: AN INTEGRATIVE REVIEW 13

First Author Pham (2013) – MD Kaiser Permanente-Department of Obstetrics and Gynecology

(Year)/Qualifications
Background/Problem  Childhood obesity is an increasing area of concern
Statement  There is increasing evidence that gestation diabetes or hyperglycemia puts offspring at
risk for childhood obesity among other metabolic diseases.

Conceptual/theoretical  Researchers wanted to determine the risk of obesity in toddler offspring (aged 2-4
Framework years) of mothers who had gestational diabetes mellitus (GDM).

Design/  Quantitative
Method/Philosophical  Retrospective cohort study
Underpinnings  Each patient had an initial exam consisting of weight, height, and demographics.
 Data collected was used to determine patient BMI which was the primary factor
measured.
 Gestational weight gain was determined by the final data collected at 37 weeks
gestation.
 1-hour glucose tolerance tests were conducted between 24 and 28 weeks of gestation
 Patients who failed the 1-hour moved on to have the 3-hour test
 Toddler offspring BMI data was collected via EMR and BMI’s greater than the 85th
percentile were defined as overweight and obese.
Sample/  2,644 women met the study cohort selection criteria (459 women in GDM group and
Setting/Ethical 2,185 in the non GDM group)
Considerations  Researchers were only able to collect BMI data for 255 of the 459 GDM woman
toddler pairs at the 2-4 year mark and 1,838 of the 2,185 in the non GDM group
 Kaiser Permanente Northern California in Santa Clara medical center (tertiary care
teaching hospital with outpatient clinics)
 Study was approved with waiver of consent by the Kaiser Foundation Research
Institute Institutional Review Board
Major Variables  GDM group – mothers with gestational diabetes mellitus
Studied (and their  Non GDM group – mothers without gestational diabetes mellitus
definition), if
appropriate
AN INTEGRATIVE REVIEW 14

Measurement  Data was collected via physical exams at different points in the study
Tool/Data Collection  Height and weight of expectant mothers was collected to determine BMI at 8 weeks
Method gestation and again at 37 weeks gestation to determine gestational weight gain.
 BMI was collected for toddler offspring via EMR at 2-4 years of age.

Data Analysis  Statistical analysis preformed using the SAS Statistical Analysis System for Windows
9.13, and P<.05 was considered significant.
 Differences in GDM status were determined with Pearson [chi]2 test for categorical
variables and Student t test for continuous variables.

Findings/Discussion  GDM was not associated with increased risk of toddler overweight and obesity.
 Toddler overweight and obesity is, however, related to pre-pregnancy overweight and
obesity of the mother.

Appraisal/Worth to  These findings can be implemented into practice by educating expectant mothers
practice about maintaining a healthy body weight to prevent putting future offspring at risk for
obesity.
AN INTEGRATIVE REVIEW
First Author Zhu (2016) – Division of Intramural Population Health Research, Eunice Kennedy Shriver
(Year)/Qualifications National Institute of Child Health and Human Development, NIH Rockville, MD
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
15
 The long-term effects of childhood obesity warrants identification of early life risk
factors that may predispose individuals to this condition
 Gestational diabetes is a common metabolic disorder in pregnant women that is
theorized to have a connection to childhood obesity.
 Researchers wanted to find out if there was a correlation between fasting plasma
glucose (FPG) concentrations during pregnancy and offspring growth and risk of
overweight/obesity through age 7 years.
 Quantitative
 FPG was taken at 28 weeks gestation from medical records of patients within the
study
 Offspring’s ponderal index was derived from birth weight and length; age- and sex-
specific BMI scores at 5 months, 12 months, and 7 years.
 Relations between FPG and offspring obesity rates were then assessed
 Form interviews were collected at 12 and 30 weeks of gestation.
 661 pregnant women with gestational diabetes took part in this study
 Data from the Danish National Birth Cohort (DNBC) which is a longitudinal
nationwide study including 101,042 pregnancies.
 Lack of follow up by participants led there to be only 405, 397, and 351 mother-
offspring pairs with available data on offspring measures at the 5 month, 12
month, and 7 year follow up, respectively.
 No ethical considerations listed.
 Women with GDM
 Covariates included: parity, socioeconomic status, pre-pregnancy BMI, and
smoking during pregnancy.
 Data was collected from EMR and form interviews
AN INTEGRATIVE REVIEW 16

Data Analysis
 Statistical analyses were conducted with SAS version 9.4
 Two-tailed P values <0.05 were considered statistically significant

Findings/Discussion  At 7 years of age, high maternal FPG concentrations were significantly associated
with increased BMI
 Maternal FPG concentrations during pregnancy were positively associated with
offspring birth size and overweight/obesity risk at 7 years of age.
Appraisal/Worth to
practice  Knowing that increase FPG concentrations are associated with childhood obesity
allows medical professionals to be proactive in educating and helping pregnant
women to manage their concentration and maintain tighter glycemic control to
decrease risk of childhood obesity in their offspring.
AN INTEGRATIVE REVIEW
First Author Morgan (2013) – College of Medicine, Swansea University, Swansea, Wales, United
(Year)/Qualifications Kingdom
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
Findings/Discussion
17
 Gestational diabetes is linked to complications in pregnancy and is recognized as
a modifier of growth and development in the fetus
 Researchers wanted to see if the influence that GDM has on the fetus extends to
childhood (1-5 years).
 Quantitative
 Population based electronic cohort study
 Maternal diabetes status was determined through EMR
 Offspring weight at birth and ages 1 and 5 years was also determined via EMR
 Logistic regression models were used to obtain odds ratios to describe the
association between maternal diabetes status and offspring size.
 147,773 mother-child pairs
 All data was collected from the Health Information Research Unit Swansea
University, UK
 Women without diabetes
 Women with pre-pregnancy diabetes
 Women with gestational diabetes
 Women who developed diabetes post pregnancy
 Healthcare data for each participant was routinely collected through electronic
medical records
 All statistical analyses were performed using STATA version 12.
 Binary logistic regression was used to calculate odds ratios
 Evidence was found linking diabetes in pregnancy to larger birth weight
AN INTEGRATIVE REVIEW 18

 There is limited evidence that diabetes in pregnancy leads to a large weight of the
child at 5 years
 More research is necessary to determine parameters surrounding maternal
diabetes and offspring size.
Appraisal/Worth to  These findings can be implemented into practice by educating expectant mothers
practice about maintaining a healthy body weight to prevent putting future offspring at risk
for obesity.
AN INTEGRATIVE REVIEW
First Author Zhao (2016) – Tianjin Women’s and Children’s Health Center, Tianjin, China
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
19
 Childhood obesity is rapidly increasing in both developed and developing
countries.
 Various environmental factors are thought to be to blame for this
 Some studies show that there may be an association between GDM and
childhood obesity
 To examine the association between maternal gestational diabetes mellitus (GDM)
and childhood obesity at age 9-11 years in 12 countries around the world.
 Quantitative
 Multinational cross-sectional study
 Study took place across 12 countries
 Researchers identified mothers of children 9-11 years of age and assessed the
mother and child’s BMI and other weight related factors.
 Mothers were asked about history of GDM with the pregnancy of the child.
 A food frequency questionnaire was dispersed to participants
 Measurements were taken of mother and child for BMI, height, weight, waist
circumference, and body fat percentage
 Institutional review board at the Pennington Biomedical Research Center
approved the research protocol, and each individual review board at the different
facilities approved local protocol.
 Written informed consent was obtained from parents or legal guardians, and child
assent was also obtained
 GDM
 Non-GDM
 A survey was dispersed to evaluate food frequency and habits
 Measurements were taken from each participant
AN INTEGRATIVE REVIEW 20

Data Analysis  Analyses were performed with SPSS for Windows version 21.0 or SAS for
Windows, version 9.4.
 Multilevel linear regression models were used to estimate the association between
maternal GDM and z scores of childhood BMI, waist circumference, and body fat.

Findings/Discussion  After adjusting for all confounders of the study, children of GDM mothers had
significantly higher mean values for BMI, waist circumference, and body fat
percentage than children of non-GDM mothers.
 These results were not fully independent of maternal BMI

Appraisal/Worth to  This study proves that GDM does have an impact on the prevalence of childhood
practice obesity, but that impact may also be related to high maternal BMI.
 More education is needed for parents about maintaining a healthy weight
themselves so as to encourage a healthy lifestyle and weight in their children.
AN INTEGRATIVE REVIEW
First Author Landon (2015) – Department of Obstetrics and Gynecology, The Ohio State University
(Year)/Qualifications College of Medicine, Columbus, OH
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied
(and their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
21
 Gestation diabetes is increasing in prevalence as is childhood obesity
 Treatment of gestational diabetes could be linked to better outcomes later in life
for the offspring of mothers with GDM.
 Researchers want to see if there truly is a relationship between treatment of GDM
and decreased incidence of lifelong complications in offspring such as childhood
obesity.
 Quantitative
 Follow-up study of participants from a Eunice Kennedy Shriver National Institute of
Child Health and Human Development Maternal-Fetal Medicine Units (MFMU)
Network randomized clinical trial for mild GDM.
 Mild GDM was defined as fasting glucose level <95 mg/dL and two of three timed
measurements that exceeded established thresholds.
 “Follow-up study of the offspring from a randomized treatment trial for mild GDM to
determine whether treatment influences child health outcomes.”
 Eunice Kennedy Shriver National Institute of Child Health and Human
Development MFMU.
 500 participants enrolled
 No ethical considerations
 Offspring of mothers treated for GDM
 Offspring of mothers not treated for GDM
 Waist circumference
 Fasting plasma glucose
 Blood pressure
 Original health records found in EMR
 Physical exams of participants
AN INTEGRATIVE REVIEW 22

 SAS statistical software (SAS Institute, Cary, NC) was used for the analyses.
 Tests were two-tailed and P<0.05 was used to define statistical significance
 No imputation for missing data was performed

Findings/Discussion  No difference was observed in obesity rate for offspring of mothers who were
treated for GDM versus mothers who were not treated.

Appraisal/Worth to  This knowledge allows for a better understanding of the predisposing factors of
practice childhood obesity as well as the effects of GDM treatment on maternal offspring.