Maternal Life Style-Journal

26/06/2015
www.medscape.com/viewarticle/844506_print
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MaternalLifestyleCharacteristicsDuring
Pregnancy,andtheRiskofObesityinthe
Offspring
AStudyof5,125Children
StamatisPMourtakosKonstantinosDTambalisDemosthenesBPanagiotakosGeorgeAntonogeorgosGiannis
ArnaoutisKonstantinosKarteroliotisLabrosSSidossis
BMCPregnancyChildbirth.201515(66)
Abstract
BackgroundToinvestigatetheassociationbetweengestationalweightgain,maternalageandlifestylehabits
(e.g.,physicalactivity,smoking,andalcoholconsumption)duringpregnancy,withBodyMassIndexoftheoffspring
attheageof8.
Methodsrandomsampleof5,125childrenwasextractedfromanationaldatabaseandmatchedwiththeir
mothers.Withtheuseofastandardisedquestionnaire,telephoneinterviewswerecarriedoutforthecollectionof
informationlike:maternalageatpregnancy,gestationalweightgain(GWG),exerciselevels,smokingandalcohol
consumption.TheBodyMassIndex(BMI)statusoftheoffspringattheageof8wascalculatedfromdataretrieved
fromthenationaldatabase(e.g.,heightandweight).
ResultsTheoddsforbeingoverweight/obeseattheageof8for1kgGWG,forsmoking,andformildexercise
duringpregnancycomparedtosedentarywas1.01(95%CI:1.00,1.02),1.23(95%CI:1.03,1.47)and0.77(95%CI:
0.65,0.91),respectively.FurtheranalysisrevealedthatoffspringofwomenwhoexceededtheInstituteofMedicine
(IOM)maternalweightgainrecommendationswereatanincreasedriskofobesity(OR:1.4595%CI,1.26,1.67)
comparedwithoffspringofwomenwithGWGwithintherecommendedrange.Maternalageandalcohol
consumptionwerenotassociatedwiththeoutcome(p>0.05).
ConclusionGWG,physicalactivityandsmokingstatusduringpregnancyweresignificantlyassociatedwithobesity
fortheoffspringattheageof8.Healthcareprofessionalsshouldstronglyadvisewomentonotsmokeandto
performmoderateexerciseduringpregnancytopreventobesityintheoffspringinlaterlife.
Background
Atthedawnofthe21stcenturythelargerpartofhumanityfacestwomajorepidemics:thesedentarylifestyleand
theobesityepidemic.Thesetwousuallycoexist,actsynergisticallytoaffectthehealthofindividuals,andaffect
peopleregardlessofsexandage. [1]AmongthecountriesoftheEuropeanUnion,morethanhalfoftheadult
populationisclassifiedasoverweightorobese,basedontheirBodyMassIndex(BMI)25. [2]
Obesityduringpregnancyincreasestheriskforadverseoutcomesbothinmaternalandoffspringhealth(e.g.,pre
eclampsia,gestationaldiabetes,hypertension,birthbycaesareansection,etc.). [3,4]Thesearesignificantconcerns
forwomenwhoareobeseatthetimeofconception,buthealthrisksincreasedramaticallyasmothersgain
excessiveweightduringpregnancy.Theextraweightgainedduringpregnancymayremainaftersuccessive
pregnanciesanditispossiblyrelatedtoadverseoutcomesinthehealthofthemother. [5]Accordingtothe2009
InstituteofMedicine(IOM)recommendations,about42%ofwomenbeganpregnancyin20042007asoverweight
orobeseand51.2%gainedexcessiveweight(>23kg)duringtheirpregnancy. [6]Thesefindingsalongwiththe
increasingincidenceofobesitysuggestthatproblemsassociatedwiththeaforementionedparameterswillalso
emergeinthefuture.
Researchersthathaveconductedobservationalstudiesreportanassociationofchildhoodobesitywithspecific
characteristicsofpregnancysuchasmaternalobesitybeforepregnancyandgestationalweightgain(GWG). [710]
GWGhasalsobeenassociatedwithgreateroffspringBMIinchildhoodandearlyadulthood. [11]
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Childhoodobesityisaworldwideepidemic. [12,13]Thenumberofoverweightchildrenisexpectedtoriseby1.3
millionperyear,withmorethan300,000ofthesechildrenbecomingobeseeachyear. [2]Greeceisamongthe
Europeancountrieswiththehighestlevelsofchildhoodobesityandstudiesreportadramaticincreaseinits
prevalence(52%). [14]Moreover,inthelastdecadeasignificantincreasewasobserved,(~30%),intheratesof
overweight8to9yearoldchildrenofbothgendersinGreece. [1517]
Maternalhealthbeforeandduringpregnancyandperinatalfactorssuchasphysicalactivity,smokingandalcohol
consumptionduringpregnancymayplayanimportantroleinthehealth,development,andBMIstatusofthe
offspringinthefuture. [18]Manyprospectivestudiesshowthatchildhoodobesityisassociatedwithspecific
characteristicsofpregnancy,suchasmaternalobesity,GWG,birthweight,pregnancysmokingstatus,alcohol
consumption,gestationaldiabetes, [7]andbreastfeeding. [11]
Althoughobesityinchildhoodandpreadolescenceisincreasingwithalarmingrates,longtermepidemiologicaldata
thatinvestigatethelinkbetweenmaternalcharacteristicsduringpregnancyandobesitystatusoftheiroffspringin
childhoodandpreadolescencearelimited.CurrentevidencesuggeststhatGWG,smokingandalcohol
consumption,aswellasexerciseduringpregnancyindependentlycouldbeassociatedwiththedevelopmentof
childhoodobesity. [7,19]However,nostudyhaseverexaminedtheeffectofalltheaforementionedvariablestaken
together.Thus,theaimofthepresentstudywastodeterminehowmaternalage,GWG,exerciselevelsduring
pregnancy,alcoholconsumptionandsmokingarerelatedtoobesityoftheoffspringinpreadolescence(e.g.,8
years).Thefindingsofthisanalysiswillprovideinformationonappropriateinterventionsduringpregnancythat
couldpotentiallypreventchildhoodandpreadolescenceobesity.
Methods
StudyDesign
Populationbaseddata,derivedfrom11nationalschoolbasedhealthsurveys,wereobtainedfromadatabasethat
includedanthropometricdata(e.g.,weight,height,etc.),aswellascontactdetailsofalmostallGreekchildrenwho
attendedprimaryschoolduring19972007,withtheexceptionof2002(e.g.,totalsample671,715primaryschool
pupils,aged79yearsold),followinganofficialrequesttotheGreekMinistryofCultureandtheMinistryof
Education.Thenationaldatabaseincludedanthropometricdataandinformationonage,gender,cityandarea,
homeaddressandtelephonenumber,whichwerecollectedyearly,atthesametimeperiod(spring),from1997to
2007,withtheexceptionof2002,inalmostallschoolsofPrimaryEducation(roughly85%)schoolsthatdidnot
participatewerefromborderlandareas,withsmallnumbersofchildren.Thus,from1997to2007,atotalof
651,5828to9yearoldchildren(51%boysand49%girls,over95%ofthetotalstudentpopulation)participatedin
thestudy.MeasurementswereperformedbytwotrainedPhysicalEducation(PE)teachersineachschool.PE
teachersfollowedaspecificprotocoltaughtincorrespondingseminarsheldbytheGreekGeneralSecretariatof
Sports(GSS).Thesameprotocolwasemployedinallschools.
DataExtraction
Asampleof5,500children(0.8%oftheentirepopulation)wasrandomlyextractedfromthedatabaseandtheir
motherswerecontactedbytelephone.Randomextractionwasperformedthroughstatisticalsoftware.Thenumber
of5,500subjectswasadequatetoachievestatisticalpowergreaterorequalto99%forevaluatinga0.100.05
changeintheregressioncoefficientsat5%significanceleveloftwosidedtestedhypotheses.Therandomsampling
wasstratifiedaccordingtotheregionandplaceofliving(e.g.,rural/urban),accordingtotheNationalStatistical
Agencyandequallydistributedduringthestudyperiod(i.e.,500mothersperyear).Thewomenthatrefusedto
participateinthestudywere183(3.3%).Thesampleofmotherchilddyadscoveredallgeographicalregionsof
Greece(e.g.,mainlandGreeceandtheislands).AllmothershadGreeknationality.
TheinformationoftheproposedprotocolwascollectedthroughtelephoneinterviewsbasedontheComputerAided
TelephoneInterviews(CATI)method.Inordertovalidatetheprocess,100facetofaceinterviewswereconducted
tocheckfordiscrepancieswiththeinformationcollectedbytelephone.Nosuchdiscrepancieswerenotedinanyof
thevariablesevaluated.
Measurements
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Allthenecessaryinformationwascollectedusingastandardisedquestionnaire,namedtheChildhoodObesity
PregnancyDeterminants(ChOPreD)questionnaire,designedanddevelopedwiththecollaborationofthe
HarokopeioUniversityDepartmentofNutrition&DieteticsandDepartmentofGeographyandtheUniversityof
TexasMedicalBranchDepartmentofInternalMedicine.TheChOPreDquestionnairewastestedandinternally
revisedbystudy'sinvestigatorsduringapilotstudy,whichconfirmeditsconstructvalidity.
Duringdatacollection,themotherswereaskedtoprovideinformationcontainedintheirpregnancyultrasound
records(e.g.,bodyweight)andrecallcertaininformation(e.g.,exerciselevels,smokingpatternsandalcohol
consumption).MothersinGreecehaveultrasoundsatthestartofthepregnancyandseveraltimesduringits
progressandreceiverecordsoftheresults.Onlymothersthathadfullsetofrecordswereincludedinthestudy,
whichfinalisedthesampleof5,125motherchildrendyads.Datarecallrelatingtotheperinatalperiodisvery
commoninpregnancyrelatedstudies.
TheBMIdataforthechildrenwascalculatedbasedondataretrievedfromthenationaldatabase.TheBMIstatus
oftheoffspringattheageof2and8wasdeterminedbasedoncutoffpointssuggestedbyCole. [20]GWGwas
calculatedbasedonthedifferencebetweenthemother'sweightatthelastandfirstvisits,basedonultrasound
records.RelativeGWGwascalculatedbasedonthedifferencebetweenlastandfirstvisitcomparedtofirstvisit.
Forthepurposesofthecurrentstudy,physicalactivityisdefinedasanyformofbodilymovementproducedby
skeletalmusclesthatincreasesenergyexpenditureoverthelevelofphysicalrest,therebyofferingnumerous
benefitsforthehumanbody.Thiscanincludeawiderangeofactivities,suchasleisureactivities,participationin
organisedsports,exercise,physicalwork,etc.. [21]Theassessmentoftheexercisewasbasedonfrequency(e.g.,
Never0times/wk,Rare1time/wk,Often36times/wk,Daily7times/wk),andduration(e.g.,exercisemorethan
therecommended30minutes)ofphysicalactivity.Thequestionnairedidnotevaluateintensity,asonlymild
intensityexerciseisrecommendedduringpregnancy. [22]
Cardiorespiratoryfitnessexerciseswererecordedasaerobicactivities,whereastheonesthatinvolvedconcentric
andeccentriccontractionsofskeletalmuscleexercisewereclassifiedasresistanceactivities. [23]Thequestionnaire
tookintoaccountactivitiesundertakenduringrecreation,exerciseorsport,aswellasdailyactivities(e.g.,activities
onedoesatwork,aspartofhouseandyardwork,etc.).Motherswereinstructedtorefertoalldomainsofphysical
activityduringtheirpregnancy.Ifamotherdidnotparticipateinanytypeofactivityshewasclassifiedasinactive.
StudyApproval
ThestudywasapprovedbytheBioethicsCommitteeofHarokopioUniversity.Oralapprovalwasobtainedfromall
motherswhoagreedtoparticipateinthestudyandwritteninformedconsentwasobtainedfromthoseparticipants
whotookpartinthevalidationprocessofthestudy.
StatisticalAnalysis
Continuousvariableswerepresentedasmeanvaluesandstandarddeviations(SD)sincetheywerenormally
distributed(asexaminedbytheuseofhistographsandPPplots)andasmedianand1stand3rdquartile.
Categoricalvariableswerepresentedasabsoluteandrelativefrequencies.OffspringBMIobesitystatus(normal
weightvs.overweight/obese)andBMIcategoriesformotherswerecalculatedaccordingtotheproposedcutoff
pointssuggestedbyInternationalObesityTaskForce(IOTF).Inordertoassessthepotentialeffectofthefollowing
maternalcharacteristics:GWG,smokingduringpregnancy,alcoholconsumptionduringpregnancyandlevelof
physicalexerciseontheoffspring'sobesitystatus,binarylogisticregressionanalysiswasimplementedandodds
ratios(OR)withthecorresponding95%confidenceintervals(CI)werecalculated.Furtheradjustmentsweremade
fortheeffectofmaternalageatpregnancy,birthweight,maternalweightstatusprepregnancyandhistoryof
breastfeeding.Priortothat,everypossibleeffectmodificationbetweentheproposedriskfactorsandthe
confounderswasexamined,butallinteractiontermswerenotstatisticalsignificant(pvalues>0.05).TheHosmer
andLemeshow'sgoodnessoffittestwascalculatedinordertoevaluatethemodel'sgoodnessoffitandresidual
analysiswasimplicatedusingthedbeta,theleverage,andCook'sdistanceDstatisticsinordertoidentifyoutliers
andinfluentialobservations.AllanalyseswereperformedusingtheSPSSversion18.0softwareforWindows
(SPSSInc.,Chicago,IL,USA).Statisticalsignificancelevelfromtwosidedhypotheseswassetatthe5%level(p
0.05).
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Results
BaselineCharacteristicsofMothersandOffspring
Thecharacteristicsofmothersandtheiroffspringarepresentedin.Themothersthatdidnothavefullsetofdata
were192(3.5%).Themothersthatdidnotwanttoparticipateinthestudywere183(3.3%).Themeanmaternal
ageatpregnancywas27.8(4.7)yearsmedian:28years,1sttertile:25years,3rdtertile:30yearsandtheage
rangewas15to48years.ThemeanGWGwas14.3(6.1)kgmedian:13kg,1sttertile:10kg,3rdtertile:18kg
andtherangewas5to45kg,whilethemedianrelativeGWG(overmaternalweightatfirstvisit)was21.7%forthe
entiresample,27.9%(1st,3rdtertile21.2%,40.0%)forunderweightmothers,22.0%(17.5%,30.0%)fornormal
weightmothers,18.6%(14.0%,25.7%)foroverweightmothersand12.9%(9.7%,18.8%)forobesemothers(data
notshown).ThemajorityofmothersstartedtheirpregnancywithnormalBMI(79.9%),while3.8%were
underweight,14.8%wereoverweightandonly2.5%wereobese.However,48.1%ofmotherswereoverweightat
theendofthepregnancy,26.5%wereobeseandonly25.4%retainedanormalBMI.Themajorityofmothersdid
notexerciseduringpregnancy(64.5%),while16.7%exercisedmoderately,13.8%sometimesperweek,andonly
3.2%oftenand1.8%daily.Only11.5%ofmotherssmokedduringpregnancy,while9.3%consumedalcohol.The
childrenhadanaveragebirthweightof3.33kgandtherangewas1.205.80kg.TheaverageBMIattheageof8
(child)was17.6(3.01)kg/m2.WithrespecttotheBMIstatusofthechildren,7.2%wereunderweight,57.2%had
normalBMI,24.2%wereoverweightand11.4%wereobese.
Table1.Characteristicsofthestudiedsampleofmothersandtheiroffspring
Offspringcharacteristics
Males,n(%)
2686(52.4%)
Females,n(%)
2439(47.5%)
Birthweight,Kg
3.33(0.50)
BMIatage8(child),Kg/m2
17.6(3.01)
BMIstatus
Underweight
370(7.2%)
Normal
2932(57.2%)
Overweight
1240(24.2%)
Obese
583(11.4%)
Maternalcharacteristics
Maternalageatpregnancy,years
27.8(4.7)
Gestationalweightgain(GWG),Kg 14.3(6.1)
MaternalBMIstatusinfirstvisit,n(%)
Underweight
194(3.8%)
Normal
4044(79.9%)
Overweight
757(14.8%)
Obese
130(2.5%)
MaternalBMIstatusinlastvisit,n(%)
Normal
1302(25.4%)
Overweight
2467(48.1%)
Obese
1356(26.5%)
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Exerciselevel
Never
3303(64.5%)
Moderate
858(16.7%)
Sometimesperweek
708(13.8%)
Often
162(3.2%)
Daily
94(1.8%)
Smokingstatusduringpregnancy,n(%)
Yes
588(11.5%)
No
4537(88.5%)
Alcoholconsumption,n(%)
Yes
476(9.3%)
No
4649(90.7%)
Dataarepresentedasabsoluteandrelativefrequenciesormean(SD).
DeterminantsofOffspring's'ObesityStatus
Logisticregressionanalysiswasconductedtoassessthepotentialeffectsofmaternalage,GWG,exerciselevels,
alcoholconsumptionandsmokingonobesitystatus(e.g.,overweight/obesevs.normal)oftheoffspringattheage
of8.Theanalysisrevealedthat1kgincreaseintheGWG(withintheobservedGWGrangevalues)wasassociated
with1.014timeshigheroddsoftheoffspringbeingoverweight/obese(95%CI:1.00,1.02)attheageof8yearsthe
ORforsmokingduringpregnancywas1.23(95%CI:1.03,1.47)and,theORformoderateexerciseduring
pregnancycomparedtosedentarywas0.77(95%CI:0.650.91).Theobservedeffectswereminimalchangedwhen
maternalageatpregnancy,birthweight,maternalweightstatusprepregnancyandhistoryofbreastfeeding.Were
enteredinthemodelaspotentialconfounders[].Additionalanalysisrevealedthattheoffspringofwomenwho
exceededtheIOMmaternalweightgainrecommendationswereatanincreasedriskofobesity(OR:1.4595%CI:
1.26,1.67)ascomparedwithoffspringofwomenwithadequateGWG.Maternalageandalcoholconsumption
werenotassociatedwiththeoutcome(p>0.05).Thepercentageofmacrosomicandunderweightbabieswassmall
andtheirinclusioninthestudydidnotaffectthestatisticalsignificanceoftheresults.
Table2.Results(OR,95%CI,p)fromlogisticregressionmodelsthatusedtoevaluatetheassociationofmaternal
characteristicswithoffspringBMIstatus(overweight/obesityvs.normalweight)attheageof8years
Predictors
Univariate
models(1) OR
95%CI
Fullmodel
p
(2) OR95%
value
CI
Fullmodel,plus
p
confounders (3) OR
value
95%CI
p
value
GWG,per1Kg
1.015(1.005
1.025)
1.014
0.002 (1.004
1.024)
0.005 1.012(1.0021.022)
0.001
Smokingstatusduring
pregnancy(Yesvs.No)
1.255(1.053
1.497)
0.011
1.232(1.03
1.47)
0.023 1.256(1.0441.511)
0.016
Alcoholconsumption
duringpregnancy(Yesvs.
No)
1.028(0.845
1.251)
0.78
1.11(0.90
1.36)
0.33
0.22
Exerciselevelduring
pregnancy
0.041
0.786(0.670
1.141(0.9241.408)
0.039
0.019
0.771
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Moderatevs.sedentary
0.923)
0.003 (0.654
0.910)
Sometimesperweekvs.
sedentary
0.958(0.809
1.135)
0.961
0.620 (0.809
1.140)
Oftenvs.sedentary
0.787(0.561
1.104)
0.166
Dailyvs.sedentary
0.884(0.574
1.362)
0.891
0.576 (0.554
1.433)
0.84(0.593
1.192)
0.002 0.747(0.6310.884)
0.001
0.646 0.953(0.8001.135)
0.59
0.329 0.87(0.6061.243)
0.44
0.636 0.955(0.5891.549)
0.85
(1) TheeffectofeachpredictorontheoffspringBMIstatuswasseparatelyevaluated (2) Includesallpredictors(i.e.
maternalageatpregnancy,gestationalweightgain,exerciselevels,alcoholconsumptionandsmokingonobesity
status) (3) Includesallpredictorsenteredinthefullmodelplus,birthweight,maternalweightstatusprepregnancy
andhistoryofbreastfeeding,aspotentialconfounders.
Discussion
TheaimofthepresentworkwastoinvestigatetheassociationbetweenGWG,maternalageandvariouslifestyle
habits,likephysicalactivity,smoking,andalcoholconsumptionduringpregnancy,withbodyweightoftheoffspring
attheageof8.ItwasrevealedthatGWG,physicalactivityandsmokingstatusduringpregnancyweresignificantly
associatedwithobesityfortheoffspringattheageof8years.Moderateexerciseduringpregnancywasfoundto
lowertheriskoftheoffspringtodevelopoverweight/obesityinchildhoodandpreadolescence,evenafteradjusting
forvariousmaternalandoffspringcharacteristics.
Thepregnancyperiodisaphaseinawoman'slifeinwhichshedevelopsagreaterawarenessaboutherhealth.
Duringpregnancy,womenaregivenasignificantopportunitytoamendsomeunhealthyhabits,likesmokingand
alcoholconsumption,toadoptamoreactivelifestyle,andtoparticipateinphysicalactivitiesand/orexercise.The
developmentandintroductionofspecificrecommendationsforphysicalactivityforpregnantwomenisrelatively
recent.Theinvestigationofphysicalactivityamongpregnantwomenbeganinthelastquarterofthe20thcentury
andcontinuestothisday.Morespecifically,earlyinvestigationsinthe1970sand1980sincludedaverycautious
approachandfocusedmainlyonpossibleadverseeffectsforthehealthofpregnantwomen,primarilybecauseof
thelimitedknowledgeaboutitsresponseofpregnantwomentoexerciseandtheevenmorelimitedknowledge
abouttheeffectsonpregnancy.Onlyrecently,researchershavebeguntofocusonthepotentialbenefitstothe
healthofmothersandtheiroffspringthatarerelatedtoparticipationinexerciseduringpregnancy.TheGuidefor
PhysicalActivityintheUSfor2008wasacrucialpoint,asitcontainedinteraliaawellwrittenandsubstantiated
chapterontheroleofphysicalactivityduringpregnancyandafterit. [24,25]Basedontherecommendations
proposedintheGuideandtherecommendationsofothercountries,itissuggestedthatpregnanthealthywomen
canexerciseatthesamelevelasnonpregnantwomen,especiallyearlyinthepregnancy.Accordingtoevidence
gatheredfromtheBehaviouralRiskFactorSurveythatwasconductedin2000,EvensonandWenreportthatmore
thantwothirdsofpregnantwomensaidthattheyparticipatedinsometypeofleisurephysicalactivity. [26]Sincethe
prevalenceofpregnantwomen'sparticipationinphysicalactivitiesisincreasing,itisimportanttounderstandthe
potentialrisksandthepossiblebenefitsofphysicalactivityduringpregnancyforwomenandtheiroffspring.
Despitethefactthatthebenefitsofexerciseforthewiderpopulationhavebeeninternationallyaccepted,theclaims
foritsbeneficialeffectsduringpregnancyhavenotyetbeensubstantiated[2731]andexerciseisnotyetsufficiently
wellacceptedasbeingbeneficialforpregnantwomen.Healthscientistsarestillscepticalandoftenreluctantto
encourageexerciseduringpregnancy,despitethewellrecognisedbenefits.Oneofthemainconcernsassociated
withexerciseduringpregnancyistheeffectoftheactivitytothefoetus,asanybenefitstothemothercanbeoffset
byadverseeffectstothefoetus.Althoughtheconcernsaretheoreticallyassociatedwiththeselectiveredistribution
ofbloodflowduringexerciseandthetransportofCO2andO2,andnutrientsbytheplacenta,ithasbeenshown
thatmoderateexerciseseemstocauseminimaltomoderateincreaseinfoetalheartratebyapproximately1030
beats/minuteabovebaseline. [28]Onthecontrary,physicalactivityduringpregnancyhasbeenshowntoimprovethe
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healthstatusofboththemotherandthefoetus.Moreover,maternalexercisemayreducetheriskforcertainrisk
factorsofpregnancyrelatedcomplications,suchasgestationaldiabetesaccordingtomanystudies. [3134]
InaccordancewiththeguidelinesforprenatalphysicalactivityintheUnitedStates,theAmericanCollegeof
ObstetricsandGynaecology(ACOG)currentlyrecommendsthatpregnantwomenareallowedtoundertake30or
moreminutesofmoderateexerciseonmost,ifnotalldaysoftheweek,iftherearenohealthproblemsand
obstetriccomplications. [32]RecommendationsforphysicalactivityfromtheAmericanMinistryofHealthpublished
in2008,statethatpregnantwomenmustparticipateinatleast150minutesofmoderateintensityaerobicexercise
aweek,eveniftheydidnotparticipateinsuchactivitiesbeforepregnancy. [35]TheAmericanCollegeofSports
Medicine(ACSM)recommendsatleast3sessionsofexerciselastingatleast15minutesandwhosedurationwill
increasegraduallyto30minutesaday,preferablyalldaysoftheweek. [36]Therecommendationsaresimilarin
Canada, [37]Denmark, [38]GreatBritain, [39]Norway[40]andAustralia. [41]
Anothersignificantriskfactorduringpregnancyisrelatedtosmoking.Itisacommonandpreventablespecific
adverseenvironmentalexposureforthefoetus. [42]Maternalsmokingduringpregnancyisassociatedwithfoetal
growthretardationandincreasedriskofpretermdeliveryandlowbirthweight. [43,44]Maternalsmokingduring
pregnancyalsoseemstoincreasetheriskofobesityintheoffspring. [45,46]
Regardingsmokingduringpregnancy,theresultsfromthepresentstudyareinlinewithotherstudiesthatshow
thatexposuretosmokingduringfoetallifeleadstooverweightandobesityinchildhood.Asystematicreview
showedthatprenatalexposuretomaternalcigarettesmokingledtoa50%increasedriskofoverweightattheage
of333yearsold. [47]Also,arecentmetaanalysisshowedthatmaternalsmokingduringpregnancywasassociated
withobesityinchildrenwithanaverageageof9years. [48]Ithasalsobeensuggestedthatthereisadoseresponse
relationshipbetweenthenumberofcigarettessmokedandtheriskofchildhoodobesity. [49]Severalstudieshave
alsoshownanassociationbetweenmaternalsmokingduringpregnancywiththehighestBMIintheoffspringorthe
increasedriskofobesityinlaterlife. [45,4951]
Moreover,ithasbeenarguedthatexposureofthedevelopingfoetustonicotinemayadverselyaffectthe
developmentofthefunctionofthehypothalamusandthroughthismechanismtohaveaneffectonappetitecontrol
duringlaterlifeandconsequentlytoincreasetheriskoffutureobesity. [52]Furthermore,studiesshowedthat
childrenofmotherswhosmokedhadahigherBMIat1yearofage, [53]andinseparatestudies,increasedBMIwas
alsoevidentattheageof6.5years, [54]8years, [55]evenin33years. [53]
Finally,anothersurvey[56]recentlyshowedthatteenagersinlateadolescencethathadbeenexposedtosmokingas
foetusesshowedhighervaluesofsubcutaneousfat(26%)andendoabdominalfat(33%).Overall,whiletheweight
gaininchildrenfromthemother'ssmokingissmall,theresultsarelongtermed.
Severalstudiesinrecentyearshaveevaluatedthereliabilityofrecalledinformationrelatingtotheperinatalperiod.
Specifically,studieshavebeenconductedinvolvingrecallintervalsfrom7to22yearsandonthewholeconcluded
thatthisinformationisreliable. [5759]
AnearliersurveybyVillaretal.(1988)showedhighcorrelationbetweenmeasuredandrecalledvariables,suchas
anthropometricmeasurementsofthemotherandtheoffspring,butlowcorrelationtofactorssuchasphysical
activityduringpregnancyandbloodpressure. [60]Finally,areviewofstudiesthatemployedphysicalactivity
questionnairesduringpregnancycomparedtoonesthatemployedobjectivemeasurements(e.g.accelerometers)
showedthattheassociationbetweenthemwaslowtomoderate. [22]Hencetheresults,asinthepresent
investigation,shouldbeinterpretedwithcaution.
Limitations
Theinformationthatwascollectedduringthetelephoneinterviewswasselfreported,andalthoughmotherscould
provideinformationbasedonhealthrecordsforthemselves,thisformsalimitationofthestudy.Moreover,a
potentiallimitationofthestudywasthatinthecurrentcohort17.3%ofwomenwereoverweight/obesebeforetheir
pregnancy,arelativelylowprevalenceincomparisontopublishedreportsforthecorrespondingpopulation. [61,62]
Thiscouldbeattributedtodeliberateunderreporting,overreportingorrecallbiasfortheselfreportedpre
pregnancyanthropometricdata(bodyweightandheight). [63]Similarobservationshavebeenpreviouslyreportedin
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GreecebyManiosetal.,2009[64]andisacommonlimitationinsimilarstudies. [65]
Finally,thesampleofmothersincludedinthestudydidnotshowstatisticallysignificantlevelsofotherriskfactors
relatedtointrauterineorfoetalgrowth(i.e.,gestationaldiabetes,increasedbloodpressure,etc.).Thus,the
researchersconcentratedtheiranalysisonlyontheriskassociatedwithGWG,maternalageatpregnancy,alcohol
consumption,smokingandexercise.
Theauthorsreportnoconflictofinterestinthereportingofthedata.
Conclusion
Theresearchanalysisthatwasconductedconfirmedthatwhenamothergainsmoreweight,adoptssedentary
behaviourandsmokesduringpregnancy,theriskthatheroffspringwillbeoverweightorobese(e.g.,higherBMI)at
theagesof8increasessignificantly.
HealthcareprofessionalsshouldadvisewomentolimittheirGWGtotherangespecifiedfortheirprepregnancy
BMIaccordingtoIOMguidelines,nottosmokeandconsumealcohol,anddomoderateexerciseduringpregnancy.
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Acknowledgements
Theauthorswanttothankthestudysubjectsfortheirwillingnesstoparticipate.WearealsoverygratefultoMrs
ChrysoulaAlexi,StavroulaParastatidouandKlairiGeorgellifortheirassistancewiththedatacollection.Thisstudy
wasconductedwiththesupportoftheInstituteforTranslationalSciencesattheUniversityofTexasMedical
Branch,supportedinpartbyaClinicalandTranslationalScienceAward(UL1TR000071)fromtheNationalCenter
forAdvancingTranslationalSciences,NationalInstitutesofHealth,OPAPSAGreece,andsupportfromthe
HarokopeioUniversityPostGraduateprogramonNutritionandDietetics.
BMCPregnancyChildbirth.201515(66)2015BioMedCentral,Ltd.
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(1) TheeffectofeachpredictorontheoffspringBMIstatuswasseparatelyevaluated (2) Includesallpredictors(i.e.

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