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

DOI: 10.1097/JPN.0000000000000005

Prevention of Childhood Obesity RiskFrom a Pre-Conceptual and PregnancyCare Perspective

Early onset childhood obesity is one of the lead-ing pediatric health concerns in the UnitedStates.1 Children who are obese before the age

of 5 years are more likely to be obese as adults, and theobesity is often more severe if it starts before the ageof 5 years. The etiology of childhood obesity is multi-factorial. However, there are several known risk factorsfor early onset childhood obesity. Several of these riskfactors occur before or immediately after the child isborn. As maternity care providers, we can help moth-ers decrease the risk of early onset childhood obesityby educating pregnant women about these known riskfactors. These risk factors are maternal obesity at thetime of pregnancy; excessive weight gain during preg-nancy; smoking before, during, and/or after pregnancy;and bottle-feeding the infant after birth.

Maternal obesity at the time of pregnancy is a chal-lenging risk factor to address. In a large study byWhitaker2 (N = 8494), it was noted that by 4 years ofage, 24.1% of children were obese if their mother wasobese during the first trimester of the pregnancy com-pared with only 9% of children whose mother was ofnormal weight during the first trimester of pregnancy.When the investigators controlled for maternal race, ed-ucation, age, marital status, weight gain, and smokingin the mother and birth weight, birth year, and genderin the children, the children with obese mothers werestill at a greater risk for early onset obesity. The relativerisk of obesity was noted early on as children were 2times more likely to be obese at the age of 3 years,and 2.3 times more likely to be obese at the age of 4years if the mother was obese during the first trimesterof pregnancy.2 In addition, in another study, Hispanicchildren and non-Hispanic white populations children

Disclosure: The authors have disclosed that they have no significantrelationships with, or financial interest in, any commercial companiespertaining to this article.

were 1.5 times more likely to be overweight or obeseduring the preschool years if their mother was over-weight or obese during the first trimester of pregnancy.3

Addressing maternal weight at the time of pregnancyrepresents a lost opportunity. Ideally, women wouldbe seeking preconceptual counseling or the topic ofprepregnant weight status would be discussed in pri-mary care visits, offering women the opportunity toconsider the potential implications of obesity shouldthey become pregnant. Healthcare providers can offercounseling, education, and resources to support weightloss for women who are obese as a component of theirregular healthcare visit. There is a fine line between cre-ating an atmosphere of support and education and therisk of creating a sense of blame or shame for womenwho are obese when they present to prenatal care. Atthe point of pregnancy, a shift in focus should occur toaddress other risk factors instead of returning to whatcan no longer be changed once she is pregnant. Thatdoes not ignore that her longer-term health will be im-proved by maintaining a healthy weight postpartum,but the emphasis for counseling can be reframed to ad-dress aspects of health she can address without creatinga sense of loss or fear regarding the factors that she canno longer change.

Once a woman is pregnant, the focus for maternitycare providers can turn to the issue of maternal weightgain during pregnancy. There is an association betweenthe amount of weight an obese mother gains duringpregnancy and early onset childhood obesity. A childwhose mother was obese and gained more than the rec-ommended amount of weight during pregnancy had a6-fold increased risk of being overweight or obese dur-ing the preschool years. However, there was no sig-nificant relationship between maternal weight gain andchildhood overweight or obesity for mothers who hada normal body mass index at the time of pregnancy.4

Not only can maternal weight gain during pregnancy

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14 www.jpnnjournal.com January/March 2014

affect a preschool-aged child’s risk of being overweightor obese, it can affect school-aged children. An obesemother who gains more than the World Health Organi-zation recommendation of 11 to 20 lb during pregnancyhad a 48% increased risk of having a child who wasoverweight or obese at the age of 7 years than motherswho gained only the recommended weight level of theWorld Health Organization.5

A mother who is obese at the time of pregnancywould benefit from ongoing nutritional support dur-ing her prenatal visits as well as in between the visits.Mothers who are obese at the time of pregnancy maybenefit from a referral to a nutritionist. The nutritionistcould provide assistance to help the mother develop adietary plan for pregnancy. Working with a nutritionistmay help the mother change current dietary practices,which would be beneficial to the mother and the un-born child. In addition, these changes may persist afterdelivery and be beneficial to both the mother and thechild. If a practice has a large number of mothers whoare obese, a nutritional support group that meets oncea month at the office may be beneficial to the moth-ers. In addition, to help decrease the risk of excessiveweight during pregnancy, obese mothers should be en-couraged to participate in an exercise program that issafe for her and her unborn child.

Finally, maternal smoking before, during, or afterpregnancy has been shown to be a risk factor for earlyonset childhood obesity. Children who were exposedto smoke in utero were more likely to be obese thanthose who were not exposed to smoke in utero.6 In ad-dition, it has been found in several studies that smokingduring the prenatal period is associated not only withoverweight and obesity but also with shortened staturein children.7 Similar to the issue of maternal obesityprior to pregnancy, the ideal would be to address therisks of smoking and obesity in children preconceptu-ally; but as it is well known, only about half of pregnan-cies are planned, so the opportunity for risk reductionpreconceptually is limited but can be addressed throughinformation campaigns about the risks of smoking gen-erally when women are seeking primary healthcareservices.

Once a woman is pregnant, there remain opportuni-ties to address the risk of childhood obesity by stoppingsmoking once she initiates prenatal care. Exposure tosmoke throughout pregnancy poses a greater risk forearly onset overweight and obesity in children thansmoking only in the early stages of pregnancy. Address-ing cessation of smoking from the initiation of prenatalcare and during each subsequent visit provides an op-portunity to support a woman to stop or at least reducethe amount she is smoking during pregnancy. The risksof smoking during pregnancy are well documented,6−9

but women may not always understand the long-termimplications for aspects as obesity. Providing this infor-mation, along with resources to support cessation, isan ongoing preventive health approach for childhoodobesity and improved maternal health in general.

Finally, breast-feeding has been shown to be protec-tive against early onset obesity in children. With all thehealth benefits documented for breast-feeding, both theAmerican Academy of Pediatrics and the World HealthOrganization have stated that breast-feeding is best foran infant and the infant needs nothing besides breastmilk for the first 6 months of life. The effects of bottle-feeding can be seen early on in life. Infants who werebottle-fed were shown to have higher weights as earlyas 3 months of life than infants who were being breast-fed.10 Infants who were bottle-fed were shown to beat 3 times greater risk of rapid weight gain during thefirst 3 years of life than those who were breast-fed.11

In 1 study of bottle-fed children, the rate of overweightor obesity by 4 years of age was double that of in-fants who were breast-fed and that rate tripled by theage of 6 years.10 Breast-feeding has also been shownto be protective against childhood obesity even if thereare other maternal risk factors for early-onset childhoodobesity. In 1 study, breast-feeding was inversely associ-ated with early-onset childhood obesity after controllingfor maternal diabetes and maternal weight status. Fi-nally, the relationship between bottle-feeding and early-onset childhood obesity was found to remain significanteven after controlling for parental education, parentalobesity, maternal smoking, high birth weight, daily tele-vision watching greater than 1 hour per day, having sib-lings, and physical activity.12 In addition to the benefitsto the infant, breast-feeding provides a significant ben-efit for the mother. Exclusively breast-feeding for thefirst 6 months of the infant’s life has been shown to helpmother lose weight during the postpartum period.13

During the course of prenatal care, the opportunityto address the benefits of breast-feeding is abundant.From entry into prenatal care, the healthcare providercan assess the woman’s desires for feed method andcan offer ongoing education and information aboutthe many benefits that have been identified for breast-feeding including the reduced risk of childhood obe-sity. The decision to breast-feed or not is not as direct,nor as simple as the desire to reduce health risks forthe baby, however, and is steeped in cultural and so-cial messaging about the women’s bodies generally andspecifically the sexualized nature of breasts. Assessingwomen’s comfort with these issues throughout the pro-cess of prenatal care and working with her to determinewhether these represent barriers or not can be an im-portant aspect of supporting her to potentially select tobreast-feed.

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The Journal of Perinatal & Neonatal Nursing www.jpnnjournal.com 15

In the process of providing counseling and educationto women about the health risks and prevention op-portunities related to childhood obesity, it is importantto note that while recent studies have shown relation-ships between maternal smoking, obesity at the timeof pregnancy, and bottle-feeding and early-onset child-hood obesity, these are only relationships and shouldnot be thought of as cause and effect. As healthcareproviders, we have to be able to walk that fine linebetween helping mothers understand the maternal fac-tors associated with early onset obesity, but do so ina way that does not blame the mother or create asense of shame that limits her comfort to work with herhealthcare provider. It is also critical to not just focus onthe health advantage of addressing the risks of child-hood obesity but to instead frame the focus on theoverall health and well-being of the mother. The para-dox of pregnancy is that for many women, it representsa time when their motivation may be high to changebehaviors or improve their health status for the sake oftheir growing baby instead of valuing the benefits theywill have themselves as a result of those changes. Ma-ternity care providers have an excellent opportunity tosupport the positive health changes women may seekinitially because of their pregnancy but they can alsohighlight the benefits for the woman directly over herlife span.

Obesity is a complex health challenge for maternitycare providers to address. Prenatal care represents aunique opportunity to support lifelong healthy lifestylechanges for women. It also promotes optimal oppor-tunities for children to avoid the risks of obesity andother health concerns by addressing maternal weightgain during pregnancy, smoking cessation, and breast-feeding to promote improved health for both mothersand their children.

—Nicole Boucher, PhD, MS, CPNP

Clinical InstructorUniversity of Michigan

400 North Ingalls, Ann Arbor, MI 48109(nbouche@med.umich.edu).

—Lisa Kane Low, PhD, CNM, FACNM

Associate ProfessorUniversity of Michigan

400 North Ingalls, Ann Arbor, MI 48109kanelow@med.umich.edu

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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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