The Impact of WIC on Birth Outcomes - Home | The National .../media/Files/Activity Files... · The Impact of WIC on Birth Outcomes ... 220 Normal Glucose Tolerance and 195 GDM women

The Impact of WIC on Birth Outcomesp

Patrick M Catalano MD.Case Western Reserve University

Cleveland, Ohio U.S.A.

Current Objectives of the WIC ProgramCurrent Objectives of the WIC Program

WIC's Mission:To safeguard the health of low-income women, infants, and children up to age 5 who are at nutrition risk by providing nutritious foods to supplement diets, information on healthy eating, and referrals to health care.y g,

More about WIC:

WIC is effective in improving the health of pregnant women, new mothers, and their infants. A 1990 study showed that women who participated in the program during their pregnancies had lower Medicaid costs for themselves and their babies than did p gwomen who did not participate.

WIC participation was also linked with longer gestation periods, higher birthweights and lower infant mortalityy

Adult Obesity 2007 Ad lt Di b t 2007Adult Obesity, 20070-26.2 >30.9

age-adjusted percent

Adult Diabetes, 20070-7.0 >10.6

age-adjusted percent

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics MMWR 58; 2009

The only series consistent with growth in WIC is SGA

2000

22000.12Rate of SGA and Number of WIC Recipients (Women)

1200

14001600

18002000

ts (W

omen

)

0.08

0.10

Ges

tatio

nal A

ge

400

600800

10001200

No.

of R

ecip

ien

0 02

0.04

0.06

te o

f Sm

all f

or G

0

200400

0.00

0.02

Rat

1980 1985 1990 1995 2000 2005

R t f SGA N f R i i t (W )Rate of SGA No. of Recipients (Women)

Source: Chris Swann, UNC Greensboro. See also www.bepress.com/bejeap/vol110/iss1/art21

MetroHealth Medical Center% I i Bi th W i ht 1975 2003

4200

% Increase in Birth Weight 1975-2003gr

ams)

5th Centile10th Centile50th Centile90th Centile

3800

4000

4200

wei

ght (

g

95th Centile

3200

3400

3600

Birt

h

2800

3000

3200

1975

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2400

2600

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2Catalano, Obstet Gynecol; 2007

Trends in Preterm Birth among singletonsTrends in Preterm Birth among singletons are not consistent with “WIC Works.”

2000

22000.12Rate of Preterm and Number of WIC Recipients (Women)

1200

14001600

18002000

ts (W

omen

)

0.08

0.10

rete

rm

40060080010001200

No.

of R

ecip

ien

0 02

0.04

0.06

Rat

e of

Pr

0

200400 N

0.00

0.02

1980 1985 1990 1995 2000 2005

Rate of Preterm No. of Recipients (Women)

Source: Chris Swann, UNC Greensboro. See also www.bepress.com/bejeap/vol110/iss1/art21

Preterm BirthsPreterm Births

Martin Final Data 2005

Adjusted Absolute Risks for Pregnancy OutcomesPregnancy Outcomes

Nohr, Am J Clin Nutr; 2008

Weight Gain Exceeds IOM GuidelinesWeight Gain Exceeds IOM Guidelines

1993-94 2002-03

Normal

% >IOM recommend 35 4 38 4% >IOM recommend 35.4 38.4

OverweightOverweight

% >IOM recommend 57.1 63.0

Obese

% > IOM recommend 42.7 46.3

Source: Table 2-7, IOM (2009); Data CDC

Maternal Pre-gravid BMI < 25Maternal Pre-gravid BMI < 25

V i bl < 10 k 10 20 k > 20 k lVariable < 10 kgs 10 – 20 kgs > 20 kgs p-value(n = 29) (n = 137) (n = 47)

Mat Wt Gain 7.7 + 2.1 14.4 + 2.8 23.0 + 2.6Birth Weight 3 093 + 0 470 3 275 + 0 491 3 490 + 0 456 0 002Birth Weight 3.093 + 0.470 3.275 + 0.491 3.490 + 0.456 0.002Lean Body Mass 2.810 + 0.378 2.931 + 0.380 3.047 + 0.339 0.02Fat Mass 0.283 + 0.148 0.344 + 0.169 0.443 + 0.187 0.0002% Body Fat 8.9 + 3.9 10.1 + 4.1 12.3 + 4.6 0.001

EGA 38.8 + 1.3 39.0 + 1.1 39.3 + 1.3 0.15Gender (M/F) 15 / 14 66 / 71 30 / 17 0.18Group (NGT/GDM) 17 / 12 101 / 36 29 / 18 0.13Race (C/AA/H/O) 19 / 8 / 2 / 0 108 / 16 / 10 / 3 33 / 6 / 6 / 2 0 25Race (C/AA/H/O) 19 / 8 / 2 / 0 108 / 16 / 10 / 3 33 / 6 / 6 / 2 0.25Parity (0-1/>1) 15 / 14 79 / 58 22 / 25 0.41Smoke (No/Yes) 26 / 3 111 / 26 37 / 10 0.46Mat Age 27.4 + 6.3 29.3 + 5.8 26.8 + 6.7 0.03

Maternal Pre gravid BMI > 30Maternal Pre-gravid BMI > 30

Variable < 10 kgs 10 – 20 kgs > 20 kgs p-value(n = 67) (n = 58) (n = 21)

Mat Wt Gain 4.7 + 0.6 14.8 + 3.1 26.2 + 7.9Birth Weight 3.446 + 0.579 3.615 + 0.524 3.445 + 0.597 0.20% Body Fat 11.6 + 4.6 14.0 + 4.8 12.5 + 6.1 0.02Lean Body Mass 3.032 + 0.444 3.090 + 0.359 2.987 + 0.362 0.54Fat Mass 0.414 + 0.207 0.526 + 0.225 0.458 + 0.293 0.02

EGA 38.7 + 1.1 38.8 + 1.1 38.4 + 1.2 0.34Gender (M/F) 37 / 30 32 / 26 9 / 12 0.58Group (NGT/GDM) 13 / 54 13 / 45 4 / 17 0.90Race (C/AA/H/O) 33 / 25 / 6 / 3 32 / 18 / 7 / 1 10 / 6 / 4 / 1 0.80Parity (0-1/>1) 30 / 37 30 / 28 10 / 11 0.74Smoke (No/Yes) 55 / 12 44 / 14 13 / 8 0.16Mat Age 29.4 + 5.9 28.4 + 6.2 27.8 + 6.0 0.51

Factors Relating to Fetal Adiposity at BirthFactors Relating to Fetal Adiposity at Birth

220 Normal Glucose Tolerance and 195 GDM women

Fat Mass r2 Δr2

Pre-gravid BMI 0.066 -EGA 0.136 0.070Wt. Gain 0.171 0.035Group (GDM) 0.187 0.016 p=0.0001

% Neonatal Body Fat

Pre-gravid BMI 0 072 -Pre gravid BMI 0.072EGA 0.116 0.044Wt. Gain 0.147 0.031Group (GDM) 0.166 0.019 p=0.0001p ( ) p

Catalano, BJOG; 2006

Maternal characteristics in Relation to% B d F t t A 8% Body Fat at Age 8

T til 1 T til 2 T til 3 lTertile 1 Tertile 2 Tertile 3 p value(n=21) (n=21) (n=21)

% Body fat (DXA) 19 7+2 6 28 2+2 6 39 3+4 3 0 0001% Body fat (DXA) 19.7+2.6 28.2+2.6 39.3+4.3 0.0001CDC weight percentile 39.8+27.5 66.0+19.1 88.0+11.4 0.0001

A t d li ( ) 30 7 3 8 29 8 5 2 31 6 4 6Age at delivery (yr) 30.7+3.8 29.8+5.2 31.6+4.6 nsHeight (cm) 167+6 166+7 166+9 nsPre-gravid weight (kg) 64.8+15 66.2+13 84.4+26 0.002Pre-gravid BMI (kg/m2) 23.5+6.1 23.9+4.0 30.8+9.3 0.0001Weight Gain (kg) 14.2+6.9 14.3+5.7 11.6+7.6 ns

Catalano; AJCN, 2009

Predictors of Childhood ObesityPredictors of Childhood Obesity

Maternal pre-gravid BMI > 30 O R 7 60 95% CI (2 2 26 6) p = 0 001O.R. 7.60, 95% CI (2.2 - 26.6) p = 0.001

Maternal pregravid BMI adjusted for gender and GDMO.R. 11.3, 95% CI (2.1 - 61.9) p = 0.005( ) p

Recommendations

Increasing Maternal Obesity and Weight Gain During PregnancyThe Obstetric Problems of Plentitude

A balanced diet with low, simple sugars and saturated fats coupled with a moderate exercise regimen, such as regular walking or swimming, should be advised for the otherwise healthy woman.

A consult with a registered dietician familiar with the nutritional needs of pregnant women may be of particular help with dietary advice for obese women. Because many general obstetrician– gynecologists are the primary health care providers, encouraging attainment of ideal body weight before pregnancy through responsible lifestyle measures is a laudable, albeit difficult, goal.

Additionally, an opportunity that has been relatively overlooked is the issue of postpartum weight reduction, at least to the level of a woman’s pregravid weight, so as not to compound the problem of increasing pregravid weight with successive pregnancies. As an example, supporting increasing participation and length of breastfeeding has both maternal and neonatal advantages to weight control.

Catalano, Obstet Gynecol; 2007

Research Recommendations

The dollar amount available for this research is relatively small, hence we need to address a specific question(s).

B d il bl id d di i d t f th h lth f thBased on available evidence and discussions, we need to focus on the health of the mother which will then be reflected in the health of the offspring.

Most importantly, addressing the health of the pregnancy begins ideally beforeMost importantly, addressing the health of the pregnancy begins ideally beforepregnancy but at the very least early in pregnancy then through the postpartum (interconceptional) period. Pregnancy offers a teachable moment.

Th h b d fi iti d t b lti i lt i l di P di t i i OBThe research by definition needs to be multispecialty, including Pediatricians, OBs and allied health professionals such as nutritionist and physical educators.

The importance of lifestyle needs to be emphasized; diet, exercise, smoking p y p ; , , gcessation etc.

Some of the Recommendations from Joyce and Liu

Joyce:Improving maternal health as the mechanism by which to improve infanth lthhealth

LIUWIC should conduct and/or support nutritional supplementation studies thatWIC should conduct and/or support nutritional supplementation studies thatbegin in the interconception period

IADPSG Recommendations f th Di i f GDM i Pfor the Diagnosis of GDM in Pregnancy

iGDM = 1 or more values > threshold

Plasma Glucose mg/dl mmol/l > threshold (%)

FPG 92 5.1 8.3

1-hr OGTT-PG 180 10.0 14.0

2-hr OGTT-PG 153 8.5 16.1

IADPSG, Diabetes Care 2010

High BMI and Adiposity (>80th percentile)b R th i Gby Race-ethnic Group

Flegal, Am J Clin Nutr; 2010

New Cases of Type 1 and Type 2 Diabetes Among Youth by Race/Ethnicity,

< 10 years old 10–19 years old

40

50

ar) Type 1 Type 2

30

40

0,00

0 pe

r yea

Type 1 Type 2

10

20

Rat

e (p

er 1

00

0ALL NHW AA H API AI ALL NHW AA H API AI

CDC: National Diabetes Fact Sheet; 2007.

NHW=Non-Hispanic whites; AA=African Americans;H=Hispanics; API=Asians/Pacific Islanders;AI=American Indians

Trends in GDM in USA 1989-2004

Age : >35

Do you need B NO

Age : 25-34

Age: < 25

Getahun; AJOG, 2008

Increasing Trends in Birth WeightIncreasing Trends in Birth WeightM t H lth M di l C t Cl l dM t H lth M di l C t Cl l dMetroHealth Medical Center, ClevelandMetroHealth Medical Center, Cleveland

3320

3340

3280

3300

ight

(g)

3240

3260

Birt

h w

e

3200

3220

Y

B

2005200019951990198519801975 Year


Obj tiObjectives

To review the increasing trends in obesity and diabetesin the general population

To characterize fetal metabolic status:a) at birthb) in childhoodb) in childhood

Neonatal Body Composition y pat Birth in Humans

Fat Mass: 12 – 15 %I t t i i t

Fat Free Mass: 85 – 88 %

Intrauterine environment

Genetic endowment at conception

Moulton, J Biol Chem; 1923Sparks, Sem in Perinat; 1989

Insulin Sensitivity GDM WomenInsulin Sensitivity - GDM Women

0 25

0.20

0.25

ensi

tivity

CTLGDM

p = 0.0001

0.10

0.15

Insu

lin S

e

* *

*

0.0

0.05

Pre-gravid Early Pregnancy

Late Pregnancy

0.0

Catalano, AJOG; 1999

Insulin Sensitivity Obese WomenInsulin Sensitivity- Obese Women

16

BMI < 25BMI 25-30BMI > 30

0 0004

10

12

14

nsiti

vity

p = 0.0004

4

6

8

sulin

Sen

Pre-gravid EarlyPregnancy

LatePregnancy

0

2Ins

Pregnancy Pregnancy

Catalano, BJOG; 2006

Maternal Insulin Sensitivity and Neonatal Fat Mass at BirthNeonatal Fat Mass at Birth

IGTCTL-g

ravi

dIGT

15

CTLtiv

ity p

re-

10

in s

ensi

t

5

Insu

l

00 200 400 600 800

Neonatal fat mass at birth (g)Catalano, AJOG; 1995

HAPO: Associations of Glucose and Primary OutcomesPrimary Outcomes

Cord C-Peptide >90th Percentile

3035

%)

Percent Body Fat > 90th Percentile

2530

%)

05

10152025

Freq

uenc

y (%

Fasting

One Hour

Two Hour

05

10152025

Freq

uenc

y (%

FastingOne HourTwo Hour

01 2 3 4 5 6 7

Maternal Glucose Categories

01 2 3 4 5 6 7

Maternal Glucose Categories

N Engl J Med; 2008 & Diabetes; 2009

Neonatal Fat Mass and Maternal Triglycerides

1.2) r=0.46

0 53

.8

1

Mas

s (k

g)

Pre

0 6r=0.53

r=0.53

.4

.6

atal

Fat

M

Late

Early

Pre

0

.2Neo

n

00 100 200 300 400 500 600 700

Maternal Triglycerides (mg/ml)

Catalano et al, unpublished

Systemic Inflammatory Markers In Pregnant Women

L Ob

In Pregnant Women

Lean n = 53 Obese n = 68

pre-gravid BMI < 25 > 30

Adiponectin (μg/ml) 10 7+4 6 9 7+4 0 nsAdiponectin (μg/ml) 10.7+4.6 9.7+4.0 ns

Leptin (ng/ml) 31.9+20 72.1+34.7 0.0001

IL-6 (ng/ml) 2.4+1.4 4.6+3.4 0.0001

TNF–alpha (pg/ml) 1.4+0.9 1.3+0.5 ns

CRP (ng/ml) 8074 + 6467 12446 + 7918 0.004

Catalano; Diabetes Care, 2009

Body Composition in Neonates at Birth Body Composition in Neonates at Birth

GDM (n = 195) NGT (n = 220)p-value

Birth Weight (g) 3398 + 550 3337 + 549 nsLean body mass (g) 2962 + 405 2975 + 408 nsFat mass (g) 436 + 206 362 + 198 0.0002Body fat (%) 12.4 + 4.6 10.4 + 4.6 0.0001

BMI < 25 BMI > 25

Birth weight (g) 3284 + 534 3436 + 567 nsLean body mass (g) 2951 + 406 3023 + 410 nsLean body mass (g) 2951 + 406 3023 + 410 nsFat Mass (g) 334 + 179 416 + 221 0.008Body Fat (%) 9.7 + 4.3 11.6 + 4.7 0.006Weight gain (lbs) 15.2 + 5.3 13.8 + 7.5 0.001

Catalano, AJOG; 2003 Sewell, AJOG; 2006

Neonatal Metabolic Parameters at Birth

Neonates of Neonates of

Neonatal Metabolic Parameters at Birth

Lean mothersn = 53

Obese mothersn = 68 p value

Pre-gravid maternal BMI 22.0+1.9 38.4+6.3

Birth weight (g) 3217+452 3320+460 ns

Placental weight (g) 614+152 693+124 0.01

N t l b d f t % 11 6+2 9 13 1+3 4 0 02Neonatal body fat % 11.6+2.9 13.1+3.4 0.02

Cord plasma insulin (μU/ml) 7.8+3.8 9.2+4.7 0.008

Cord plasma glucose( /dl)

60+13 66+14 0.03

(mg/dl)


Estimates of Neonatal Insulin Resistance at BirthEstimates of Neonatal Insulin Resistance at Birth

*4.0

IR in

dex

2.0

3.0

HO

MA

-

0

1.0

0from lean

womenfrom obese

women

Catalano, Diabetes Care; 2009

Neonatal Insulin Sensitivity d Adi it t Bi thand Adiposity at Birth

4 0 r=0 32 p=0 0008

neonates of obese women

neonates of lean women

3.0

4.0

-IR in

dex r=0.32, p=0.0008

1.0

2.0

tal H

OM

A

0Fet

4 6 8 10 12 14 16 18 20 22Neonatal body fat (%)


Obj tiObjectives

To review the increasing trends in obesity and diabetes inthe general population

To characterize fetal metabolic status:a) at birtha) at birthb) in childhood

Maternal characteristics in Relation to% B d F t t A 8% Body Fat at Age 8

T til 1 T til 2 T til 3 lTertile 1 Tertile 2 Tertile 3 p value(n=21) (n=21) (n=21)

% Body fat (DXA) 19 7+2 6 28 2+2 6 39 3+4 3 0 0001% Body fat (DXA) 19.7+2.6 28.2+2.6 39.3+4.3 0.0001CDC weight percentile 39.8+27.5 66.0+19.1 88.0+11.4 0.0001

A t d li ( ) 30 7 3 8 29 8 5 2 31 6 4 6Age at delivery (yr) 30.7+3.8 29.8+5.2 31.6+4.6 nsHeight (cm) 167+6 166+7 166+9 nsPre-gravid weight (kg) 64.8+15 66.2+13 84.4+26 0.002Pre-gravid BMI (kg/m2) 23.5+6.1 23.9+4.0 30.8+9.3 0.0001Weight Gain (kg) 14.2+6.9 14.3+5.7 11.6+7.6 ns


Neonatal Adiposity at Birth P di t Adi it i ChildPredicts Adiposity in Children

8 50

From GDM womenFrom CTL women

r = 0.30p = 0.02

dren

age

40

y fa

t chi

ld

20

30

%bo

dy

10

20

2 6 10 14 18 22% Body fat at birth

2 6 10 14 18 22


In utero Programming of Obesity and Metabolic Dysfunction

Pregnancy

y y

Pregnancy increased insulin

resistance/inflammation

ObesityObesityDiabetes

Fetal-Neonatal Metabolic programming of Obesity

Adult metabolic syndrome T2DM -Obesity

Childhood Obesity? Pre metabolic syndrome? Pre-metabolic syndrome

Catalano; JCEM, 2003

DiabetesDiabetes-- induced Fetal Overgrowth: induced Fetal Overgrowth: th Glth Gl i li H th ii li H th i

Jorgen Pedersen, 1952

the Glucosethe Glucose--insulin Hypothesisinsulin Hypothesis

FetalFetalf tFetal

insulin fat accretion

Maternal

fetal ß cells

Maternal plasma

glucose Fetal plasma glucose

Pedersen; 1952

Perinatal Environment Obesity and Subsequent DiabetesSubsequent Diabetes

LGA fetus >>> LGA neonateLGA fetus >>> LGA neonatechildhood >>> >>> adult

obesity/diabetes

In utero Metabolic Programming of Obesity

Ob itObesityDiabetes

in pregnancy

?Neonatal

Childh d Ob itChildhood Obesity

Catalano; JCEM, 2003

Body Composition in Neonates f Ob d GDM Wof Obese and GDM Women

Lean Obese p-vs lean GDM p-vs lean(n = 195) (n=144) (n = 76)

B Weight (g) 3284+ 534 3437+ 567 ns 3398+ 550 ns

Fat Free Mass (g) 2951+ 406 3023+ 408 ns 2962+ 405 ns

Fat Mass (g) 334+ 179 416+ 198 0.0001 436+ 206 0.0002

Body Fat (%) 9.6+ 4.3 11.6+ 4.7 0.0002 12.4+ 4.3 0.0002

Catalano, AJOG; 2003/2010

I li S iti it t Bi thInsulin Sensitivity at Birthx **

8.0

dex

4.04.5

r=0.35, p=0.0002

OM

A-IR

inde

x

*4.0

2 0

6.0

HO

MA

-IR in

1.52.02.53.03.5

HO

mothersfetuses0

2.0

Feta

l

00.51.0

0 2 4 6 8 10 12

Maternal HOMA-IR index


Objectives

To review the metabolic relationship between gestational diabetes(GDM) and fetal growth/adiposity

T i th t b li l ti hi b t t ti l di b tTo review the metabolic relationship between gestational diabetes (GDM) and fetal growth/adiposity


Neonatal Body Composition in Neonatal Body Composition in GDMGDMGDMGDM

GDM NGT p-value( 195) ( 220)(n = 195) (n = 220)

Weight (g) 3398+550 3337+549 0.26Fat Free Mass (g) 2962+405 2975+408 0.74Fat Mass (g) 436+206 362+198 0.0002Body Fat (%) 12.4+4.6 10.4+4.6 0.0001

Tricep (mm) 4.7+1.1 4.2+1.0 0.0001Subscapular (mm) 5 4+1 4 4 6+1 2 0 0001Subscapular (mm) 5.4+1.4 4.6+1.2 0.0001Flank (mm) 4.2+1.2 3.8+1.0 0.0001Thigh (mm) 6.0+1.4 5.4+1.5 0.0001Abdomen (mm) 3.5+0.9 3.0+0.8 0.0001Abdomen (mm) 3.5 0.9 3.0 0.8 0.0001

Catalano, AJOG; 2003

Basal Triglyceride Concentrations in GDMGDM

p=0.02

500

NGT

300

400

de (m

g/dl

)

NGTGDM

pt = 0.0001pg = 0.04

p=0.04200

Trig

lyce

rid

Pregravid Early Late 0

100

Pregnancy Pregnancy

Objectives


T i th t b li l ti hi b t t l b it dTo review the metabolic relationship between maternal obesity and fetal growth/adiposity


Maternal Weight at DeliveryMaternal Weight at DeliveryM t H lth M di l C tM t H lth M di l C tMetroHealth Medical CenterMetroHealth Medical Center

(lbs.

)

185

190w

eigh

t (

180

185

mat

erna

l

170

175

Year

m

20051999199519911987

165


Increasing Trends in Birth WeightIncreasing Trends in Birth Weight--EuropeEuropeEurope Europe

Denmark (1990-1999)Orskou, Acta Ob/Gyn Scand; 2001

Mean birth weight• 3474→3519 Δ45g• > 4,000 g 16.7%→20% (p<0.05) 4,000 g 16.7% 20% (p 0.05)

Sweden (1992-2001)Surkan AJOG; 2004Surkan, AJOG; 2004

• 23% increase in the incidence of LGA newborns, i.e.,

• > 2 S.D. mean birth weight/gestational age

Perinatal Predictors of Childhood Obesity

Pregravid BMI > 30 O R 5 45 (95% CI 1 62 – 18 4) p<0 006O. R. 5.45 (95% CI 1.62 18.4), p<0.006

Maternal pre-gravid obesity accounts for 17.6% of childhood obesity

Increasing Trends in Birth WeightIncreasing Trends in Birth Weight--USA/CanadaUSA/Canada 1985 1998

TERM SGA

USA/CanadaUSA/Canada 1985-1998

TERM SGAUSA White ↓ 11%USA Black ↓ 12%USA Black ↓ 12%Canada ↓ 27%

TERM LGAUSA White ↑ 5%USA Black ↑ 9%Canada ↑ 24%

Anath, Sem in Perinat; 2002

Basal Triglyceride Concentrations in Ob WObese Women

500

600 BMI < 25BMI 25 to 30

BMI > 30/dl)

400

ides

(mg/

200

300

Trig

lyce

r

p = 0.0001

100

Pregravid Early Pregnancy

Late Pregnancy

0

Birth Weight and Maternal Triglycerides

Di Cianni, Diabetic Medicine; 2003

Fetal Growth and Maternal TriglyceridesFetal Growth and Maternal Triglycerides

Schaffer-Graf, Diabetes Care; 2008

Objectives


T i th t b li l ti hi b t t l b it dTo review the metabolic relationship between maternal obesity and fetal growth/adiposity

To characterize fetal metabolic status:To characterize fetal metabolic status:a) at birthb) in childhood

Risk of Fetal Macrosomia with Maternal Obesity and Diabetes

• Risk of Macrosomia (OR)• Risk of Macrosomia (OR)

Maternal Obesity (BMI > 30) 1.6Pre-gestational Diabetes (Type 2) 4.4

• Overall the population risk of fetal macrosomia, however is 4-foldgreater in the population because of the 60% prevalence ofgreater in the population because of the 60% prevalence of overweight/obese women in the population vs. 5-7% in women with diabetes.

Ehrenberg, AJOG; 2004

Metabolic Dysregulation at Age 8 According to Tertiles of AdiposityAccording to Tertiles of Adiposity

Tertile 1 Tertile 2 Tertile 3Tertile 1 Tertile 2 Tertile 3(n=21) (n=21) (n=21)

p valueChild body fat by DXA (%)19 7+2 6 28 2+2 6 39 3+4 3 0 0001Child body fat by DXA (%)19.7+2.6 28.2+2.6 39.3+4.3 0.0001

Waist circumference (cm) 55.3+5.0 62.0+6.8 72.0+8.0 0.0001

Systolic BP (mm Hg) 105+8 109+5 114+13 0.01

HOMA-IR 1.5+0.5 2.2+1.1 3.4+1.7 0.002

Triglyceride (mmol/L) 0.62+0.3 0.72+0.32 1.23+0.77 0.009

Leptin (ng/mL) 2.5+0.6 7.6+4.7 15.9+7.0 0.0001


Relationship Between Birth Weight and Child WeightBirth Weight and Child Weight

70

kg)

CTLGDM r = 0.03, p = 0.79

50

60

low

-Up

(k

20

30

40

ght a

t Fol

l

10

20

Chi

ld W

eig

2 2.5 3 3.5 4 4.5 5

C

Birth Weight (kg)


Obesity Trends* Among U.S. AdultsBRFSS 2008BRFSS, 2008

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

Source: Behavioral Risk Factor Surveillance System, CDC.

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

C l iConclusionsGDM d t l b it i k f t f i d f t l di itGDM and maternal obesity are risk factors for increased fetal adiposity,but, …. from a population perspective maternal obesity is the fargreater attributable risk factor for fetal adiposity.

At birth increased fetal adiposity is associated with increased insulinresistance.

Maternal pregravid obesity (BMI) independent of maternal glucosestatus or birth weight is the strongest predictor of childhood obesity

Placenta and WAT Resident MacrophagesPlacenta and WAT Resident Macrophagesin Pregnancy with Obesity

CD 68

CD 68

Originate from activated maternal monocytesLocalize in tissue stromal compartment

Have similar functional phenotype

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The Impact of WIC on Birth Outcomes - Home | The National .../media/Files/Activity Files... · The Impact of WIC on Birth Outcomes ... 220 Normal Glucose Tolerance and 195 GDM women