Hindawi Publishing Corporation

Journal of Obesity
Volume 2012, Artile !" #$%1%&, '
pages doi(10)11$$*2012*#$%1%&
Research Article
Maternal and Early Childhood Risk Factors for Overweight
and Obesity among Low-Income Predominantly lack
Children at !ge Five "ears# ! Pros$ective Cohort %t&dy
'aveed (afar )an*&a+
,+ -+ .
&shra Mahmood+
/
M0 !min&l Islam+
,
and Robert L0 1oldenberg
2
1
Department of Epidemiology, School of Public Health, University of Alabama at irmingham, irmingham, A! "#$%&, USA
$
'ommunicable Disease Prevention and 'ontrol Services, ritish 'olumbia 'entre for Disease 'ontrol, (## )est 1$th Avenue,
*ancouver, ', 'anada *#+ &R&
"
School of Population and Public Health, University of ritish 'olumbia, *ancouver, ', 'anada *(, 1+"
&
R,- -nternational, Research ,riangle Par., /' $001%, USA
#
Department of 2bstetrics and 3ynecology, 'olumbia University, /e4 5or., /5 111"$, USA
Correspondene should be addressed to +a,eed -afar Jan.ua, na,eed).an.ua/bd)a
0eei,ed 2% June 20121 Aepted 2% August 2012
Aademi 2ditor( "a,id Allison
Copyright 3 2012 +a,eed -afar Jan.ua et al) 4his is an open aess artile distributed under the Creati,e Commons Attribution
5iense, whih permits unrestrited use, distribution, and reprodution in any medium, pro,ided the original wor6 is properly
ited)
2b6ective) 4o identify maternal and early hildhood ris6 fators for obesity and o,erweight among hildren at age $ in the state of
Alabama) 7ethods) 7e reruited %#0 mothers during early pregnany from 8ni,ersity of Alabama Prenatal Clinis in a prospeti,e
ohort study and followed them throughout pregnany) 7e followed their hildren from birth until $ years of age) 4he main outome
measure was obesity 9:;! for age and se< '$th perentile= at $ years of age) 7e used poisson regression with robust ,ariane
estimation to ompute ris6 ratio 900=) Results) At the $th year of followup, %1 9')>?= of the hildren were obese and @$ 911)$?= were
o,erweight 9:;! @$thA<'$th perentile=) !n multi,ariable analysis, maternal prepregnany o,erweight 900( 2)&0, '$? C!( 1)2'A
#)11= and obesity 900( 2)$&, '$? C!( 1)#'A#)&1=, and hildBs birth weight >@$th perentile 900( 2)0#, '$? C!( 1)1&A &)>@= were
assoiated with hildhood obesity) ;aternal prepregnany :;!, birth weight, and maternal smo6ing were assoiated with the hild
being o,erweight 1A12 igarettes*day ,ersus 0 igarettes*day 900( 1)#0, '$? C!( 1)02A1)'1=) 'onclusion) Children of o,erweight and
obese mothers, and hildren with higher birth weight, are more li6ely to be obese and o,erweight at age $) ;aternal smo6ing 1A12
igarettes per day is assoiated with the hild being o,erweight)
,0 Introd&ction
Obesity has reahed epidemi proportions in the 8nited Ctates
98C= where, in 200%D0@, &#? of adults were obese and >@?
were o,erweight E1F) 4he situation is worse in some southern
states li6e 5ouisiana, ;ississippi, and Alabama where almost
1 person out of & is obese or o,erweight) ObeDsity is
partiularly more ommon in the AfrianDAmerian population
9##?= than in their white ounterparts 9&&?= E1F) !n 200%D0@,
among hildren 2 to $ years of age, 11? of AfrianDAmerians
ompared to $)$? of 7hites were obese and 2>? ,ersus '?
were o,erweight E2F) Compliations
of obesity are also more se,ere among AfrianDAmerians E&,
#F) 4he inreasing pre,alene of obesity and o,erweight has
important health and eonomi impliations E$, >F) !f urrent
trends ontinue, the higher pre,alene of obesity may result in
a deline in life e<petany in the 8nited Ctates E&, #F) 4his
inrease in mortality ris6 arises from a higher ris6 of many
omorbidities, inluding type 2 diabetes, hypertension,
hyperholesterolemia, osteoarthritis, gallbladder disease, and
some aners E%F) Obesity an also produe psyhologial
morbidity, espeially among women and hildren E@F) A study
fousing on the burden of obesity in the 8C has re,ealed that
relati,e to normalDweight men and women,
2
o,erweight men and women lost 2%0,000 and 1)@ million
Guality ad.usted life years in the year 2000, respeti,ely)
Obese men and women lost 1)' million and &)# million GuaD
lityDad.usted life years in the year 2000, respeti,ely E#F)
Ce,eral studies ha,e reported that early hildhood obesity
predits later obesity in adulthood1 hene pre,enti,e meaDsures
should start early during hildhood E'A12F) Ctudies ha,e
indiated that hildhood obesity is assoiated with the
de,elopment of noninsulinDdependent diabetes at an early age)
!n addition to ad,erse physial health, obese hildren are more
li6ely to suer mental health issues and psyhosoial
problems and e,en disrimination E@F)
Cine treatment and management of obesity is diult and
hildhood obesity persists during adulthood, determinDing
perinatal, and early hildhood ris6 fators pro,ides an a,enue
for early inter,entions) Ce,eral studies ha,e assessed the
fators that predit hildhood obesity) ;aternal prepregDnany
:;!, weight gain during pregnany, smo6ing during
pregnany, low soioeonomi status, birth weight, inreased
weight gain during early years, and poor home en,ironment
ha,e been reported to predit early hildhood obesity E2, $, %,
1&A1$F) Howe,er, most of studies in the 8nited Ctates ha,e
assessed the prepregnany and early hildhood ris6 fators
among predominantly white populations E1>, 1%F largely
ignoring the AfrianDAmerian and Hispani populations E1@A
21F) 7e assessed maternal and early hildhood ris6 faDtors for
being obese at $ years of age for a lowDinome preDdominantly
AfrianDAmerian ohort)
-0 Methods
$818 Study Design and Population8 "ata for this study ame
from a longitudinal study of pregnany outomes and
hildhood psyhomotor de,elopment at the age of $ years)
"etails of population and measurements ha,e been reported
pre,iously E22, 2&F) 4he mothers of hildren were reruited
from a population of lowDinome women see6ing prenatal
are through the publi health system in :irmingham,
Alabama from "eember 1'@$ to Otober 1'@@) !n this
population, <$? of the women breastDfed their infants and
,irtually all were eligible for the speial supplemental proD
gram for women, infants, and hildren 97!C=) ;others
were enrolled during early pregnany and were followed
through pregnany until deli,ery) 4heir hildren were
followed from birth until about $ years of age)
$8$8 2utcome8 4he primary outome measure in this study was
obesity among hildren at age $ years) 7e de,eloped the
outome ,ariable by employing ageD and se<Dspeifi ,alues
of :;! using the Centers for "isease Control and Pre,enD
tionBs referene growth harts for hildren and the 2<pert
CommitteeBs reommendations about hildhood obesity E2#,
2$F) Children whose ageD and se<Dspeifi :;!s were '$th
perentile at $ years of age were onsidered obese and those
with :;!s @$ and <'$th perentile were onsidered o,erD
weight E2$F)
Journal of Obesity
$8"8 Determinants8 ;ain ,ariables inluded maternal and
family attributes olleted at enrollment and during pregD
nany and hild harateristis at birth and in early hildD
hood) ;aternal data used in this analysis inluded informaD
tion regarding soiodemographi harateristis inluding,
age, rae 9bla6*white=, years of shooling, total number of
hildren in the family, total number of adults at home,
employment status of mother, and whether the family
reei,ed any 6ind of assistane from state or federal
agenies suh as 7!C or food stamps) !nformation on
mothers smo6ing status was also olleted at eah ,isit
during pregDnany) Cine there were more missing data
from the 2nd and &rd trimesters, we used 1st trimester
smo6ing status as our indiator for smo6ing during
pregnany E2>F) ;aternal prepregnany :;! was
omputed from the sub.etBs reported prepregnany weight,
and height measured at first prenatal ,isit) Prepregnany
self reported weight was highly orrelated with weight at
enrollment in first prenatal ,isit 9r = 0.'>, R
2
= 0.'2=)
Huality of the home en,ironment has been reported to
be assoiated with obesity among hildren E2%F) 7e
measured the Guality of home en,ironment using Home
Creening Huestionnaire 9HCH=) A sore of #1 and greater
reflets adeDGuate home en,ironment while less than #1
was onsidered less than adeGuate)
5ength*height and weight was measured at birth, at age
one year, and at age fi,e years)
$8&8 Statistical Analysis8 7e omputed the mean for onD
tinuous ,ariables and proportions for ategorial ,ariables
to desribe the distribution of the harateristis of study
partiipants) 7e ompared the independent ,ariables using
hiDsGuare and rossDtabulation for ategorial ,ariables
and tDtest or A+OVA or nonparametri for ontinuous
,ariables, whihe,er was appropriate)
;aternal prepregnany :;! was ategoriIed into low and
normal 9<1@)$A2#)'=, o,erweight 92$)0A2')'= and obese
9&0)0=) ;aternal smo6ing, measured as number of igaDrettes
smo6ed during the 1st trimester, was ategoriIed into highD
freGueny smo6ers who smo6ed 1& igarette per day 9@$th
perentile=, smo6ers with some degree of smo6ing 91A12
igarettes per day=, and nonsmo6ers) Age was ateDgoriIed
into <20 and 20 years, eduation into <12 grades and 12
grades, HCH sores into <#1 and #1, and the number of
hildren at home was dihotomiIed at the median into 2 and
>2) :irth weight was analyIed as a ontinuous ,ariable and
then ategoriIed based on gestational age and raeDspeifi
perentiles for the 8nited Ctates population as @$th perentile
and >@$th perentile E2@F)
7e omputed ris6 ratios 900= to estimate the assoiation
of ris6 fators with outomes) 4wo approahes ha,e been
proposed to ompute ris6 ratio in prospeti,e studies with
ommon outomes1 log binomial regression and poisson
regression with robust ,ariane estimation E1$, 2'F) 7hen
outomes are ommon, the odds ratio pro,ides inflated estiD
mates of assoiation) Cometimes log binomial regression
models do not on,erge) 7e also e<periened the same probD
lem) 4hus, we used poisson regression with robust ,ariane
Journal of Obesity
estimation to ompute rude and ad.usted 00s and '$?
onfidene inter,als implemented through Pro J2+;O"
in CAC E&0F) !nteration of prepregnany :;! and birth
weight was not signifiant) 7e also identified determinants
of o,erweight using the same approah as outlined for
obesity) 7e onduted all analyses using CAC ,ersion ')2)
.0 Res&lts
7e had data for %#0 singleton births with the infants folDlowed
to an a,erage age of $)# years) After e<lusion of ases with
missing information about the ,ariables used in the analyses,
data for >#' sub.ets were a,ailable that ontriDbuted to the
final model) 7e ompared the proportion of o,erweight
hildren between partiipants inluded in final model and
those who ould not be inluded beause of missDing
information) 7e found no signifiant dierenes betDween
partiipants who were inluded in the final model 9n = >$*>#',
10)2?= ,ersus those who were not inluded in the model 9n =
>*'1, >)>?, P = 0.&=)
"818 'haracteristics of the Study Sample8 AfrianD
Amerians onstituted the ma.ority of the sample 9%%?=)
;ost of the births ourred at term 9%'?=) 4he mean birth
weight was 2@'2)> >#1)' g with a median of 2@#$ g
9range( >#0A $1%$ g=) 4he proportion of low birth weight
95:7= was 2#? and >)%? were abo,e the @$th perentile
of birth weights in the 8nited Ctates 94able 1=) ;ean age of
the mother at the time of deli,ery was 2# years) Ci<tyDsi<
perent of the mothers had at least a 12th grade eduation,
>1? were employed, &#? were on wellfare, 1%)$? were
enrolled in 7!C, and $')2? reei,ed food stamps) 4he
mean number of hildren at home was 2)%) 4he mean 9C"=
and median ErangeF prepregnany :;! was 2#)$9%)1=
6g*m
2
, 22)$ E1&A$0F, and 1%)@? of the mothers were obese
9:;! &0= before pregnany) 4he mean 9C"= and median
ErangeF number of igarettes smo6ed during the 1st
trimester were $)# 9')$= and 0 E0A>&F1 >1)#? did not
smo6e, and 1$)&? smo6ed 1& igarettes per day 94able 1=)
"8$8 2ver4eight and 2besity8 At the $th year of followDup
,isit, ')>? of the hildren were obese aording to their
ageD and se<Dspeifi :;! using the '$th perentile as the
referene definition of obesity E2#, 2$F) At the same ,isit,
11)$? hildren were o,erweight 9:;! @$thA<'$th perD
entile= 94able 1=)
4hose hildren who had higher birth weight 9P = 0.001= or
higher weight at 1)2 years of age 9P = 0.002= were more li6ely
to be obese at the $th year of followup) Jirls were more li6ely
to be obese than boys 9>0)1? ,ersus &')#?, P = 0.0#1=) Obese
mothers were 2)' times more li6ely to ha,e obese hildren 9P
< 0.001=) Children of mothers who had <12th grade eduation
were also more li6ely to be obese as ompared to those who
ompleted 12th grade 900( 1)>%, '$? C!( 0)''A2)@&=) Ha,ing
two or less hildren at home was also assoiated with
inreased obesity 9P = 0.00%=) 2mployDment status of the
mother, use of food stamps, 7!C, materDnal age, fatherBs
eduation, rae*ethniity, Guality of home
&
en,ironment, and number of adults at home were not signiD
fiantly assoiated with obesity 94able 2=)
;ultiple poisson regression models with robust
,ariane estimation for ris6 fators assoiated with obesity
re,ealed that hildren of mothers who were o,erweight
900( 2)&0, '$? C!( 1)2'A#)11= or obese before pregnany
900( 2)$&, '$? C!( 1)#'A#)&1= were more li6ely to be
obese) KurtherDmore, hildren who were abo,e the @$th
perentile of birth weight were also more li6ely to be obese
at age fi,e 900( 2)0#, '$? C!( 1)1&A&)>@=) Ha,ing two or
less hildren at home 900( 1)>#, '$? C!( 1)01A2)>#= and
being a female hild 900( 1)>%, '$? C!( 1)0@A2)%2= were
also assoiated with being obese) Children of mothers
smo6ing 1A12 igarettes*day during the 1st trimester were
more li6ely to be obese as ompared to those who did not
smo6e 900( 1)#2, '$? C!( 0)@@2)&0= while if mothers
smo6ed 1& igarettes their hildren were less li6ely to be
obese 900( 0)$&, '$? C!( 0)22A1)2%=) +either relationship
was statistially signifiant 94able &=)
4he multi,ariable model for determinants of being
o,erDweight at age $ showed similar results 94able #=) !n
the model for hildhood o,erweight, the mother being
o,erweight or obese before pregnany, birth weight >@$th
perentile, and mother smo6ing 1A12 igarettes*day were
eah assoiated with being o,erweight) Children of mothers
smo6ing 1A12 igarettes*day during the 1st trimester were
more li6ely to be o,erweight as ompared to those who did
not smo6e 900( 1)#0, '$? C!( 1)02A1)'1=)
/0 3isc&ssion
!n this study of a predominantly AfrianDAmerian popuD
lation, we found that high prepregnany :;!, high birth
weight, fewer number of hildren at home, female se< of the
hild, and mothers smo6ing 1A12 igarettes*day during the 1st
trimester were assoiated with being both o,erweight and
obese at age $) Come of these fators suh as maternal
smo6ing and prepregnany :;! are modifiable and an be the
target of inter,entions) Others, li6e female gender and number
of hildren at home, are not modifiable) +onDmodifiable
fators stress the importane of understanding underlying
proesses and their ultural onte<t that put indi,iduals with
ertain attributes more at the ris6 of o,erDweight) A reent
analysis of data from the early hild are and youth
de,elopment longitudinal sample suggests that hildren with a
:;! @$th perentile are more li6ely to gain weight and reah
obese status as ompared to those who remain below $0th
perentile) Children who beome obese at an early age are
more li6ely to be obese during late hildhood and adolesene
E&>F) Hene, pre,ention of pediatri obesity early on is
important and may be ahie,ed by reogniIing and identifying
obesity at an early stage and oering ounDseling and
proati,e treatment strategies)
Assoiation of maternal prepregnany :;!
with pediDatri obesity has been reported
onsistently in both retrosDpeti,e and
prospeti,e ohorts E1%, 2%, &%F) A large retrosD
peti,e ohort study in Ohio reported inreased
odds of hildhood o,erweight with inreasing
maternal :;! during
# Journal of Obesity
4A:52 1( Charateristis of the partiipants and early hildhood determinants of obesity at the age of $ in Alabama 9n = %#0=)
Variables n ? ;ean C" ;edian ErangeF
;aternal harateristis
0ae
:la6 $%0 %%)0
7hite 1%0 2&)0
;other age at deli,ery 9years=
;ean 9C"= 2#)0 9#)>= 2& E1#A#&F
<20 11@ 1>)0
20A2' $&# %2)2
>2' @@ 11)@'
;otherBs mean 9C"= years of shooling 11)@ 92)2= 12 E0A1@F
;other ompleted 12th grade #@% >>)2
2mployed, ? &%# >1)1
8sing food stamps, ? &%0 $')2
On welfare, ? 1'1 &#)0
Parity, mean 9C"= 1)& 90)@= 1 E0A'F
Prepregnany :;!, mean 9C"= 2#)$ 9%)1= 22)$ E1&A$0F
:;! groups
5ow 9<1@)$= 100 1#)%
+ormal 91@)$A2#)'= &#' $1)2
O,erweight 92$A2')'= 111 1>)&
Obese 9&0= 121 1%)@
+umber of igarettes smo6ed during 1st trimester $)# 9')$= 0 E0A>&F
0 igarette #$# >1)#
1A12 igarette 9>1A@$th perentile= 1%' 2#)2
1& igarette 9>@$th perentile= 10% 1$)&
Alohol inta6e during pregnany, ? 1@> &1)'
Child harateristis
Ce<, ? female &>2 #@)'
:irth weight 9grams=
;ean 9C"= 2@'2)> 9>#2)0= 2@#$ E>#0A$1%0F
<2$00 1%> 2&)@
2$00A2''' 2$1 &&)'
&000A&'00 2@$ &@)$
#000 2@ &)@
Abo,e @$th perentile $0 >)%
Preterm, ? 1#' 20)1
:;! at age $ years
+ormal weight 9<@$th perentile = $@# %@)'
O,erweight 9@$th to <'$th = @$ 11)$
Obese 9'$th perentile= %1 ')>
the first trimester of pregnany E1%F) ;aternal prepregnany
:;! has also been reported as a ris6 fator for adiposity in
AfrianDAmerian hildren in Philadelphia E1@F) ;any
mehanisms ha,e been proposed for maternal obesity leadDing
to hildhood obesity inluding inheritane of genes that
enhane suseptibility, E1&, &@F feeding and eating beha,iors1
obese mothers may ha,e poor eating habits, whih may
negati,ely impat the intrauterine en,ironment E&'F) 4hese
findings emphasiIe the importane of hildhood obesity preD
,ention ,ery early on or e,en before the start of pregnany)
!n this study, being a female hild was
assoiated with a higher ris6 of obesity) Among
AfrianDAmerian hildren and adolesents, a
higher proportion of females are obese E2, >F) 4he
findings from the +ational Health and +utrition
2<amination Cur,ey 9+HA+2C=, +ational
Jrowth and Health Ctudy 9+JHC=, and many
other studies indiate that AfrianDAmerian girls
ha,e higher :;!s than white girls of similar ages
E2, #0A#2F) Cultural attitudes about body image
among AfrianDAmerian ommunities indiate
that AfrianDAmerians are relati,ely more
tolerant of a large
Journal of Obesity $
4A:52 2( Crude ris6 ratio and '$? C! of prepregnany and early hildhood fators assoiated with being obese 9 '$th perentile= at the
age of $)
Variable
Obese
00 '$? C!
N n ? P
Child harateristis
Ce<
;ale &%@ 2@ %)# 1)00
Kemale &>2 #& 11)' 0)0#1 1)>0 91)02A2)$2=
:irth weight 9Lg=

@$th perentile >'0 >0 @)% 1)00

>@$th perentile $0 11 22)0 0)001 2)$& 91)#2A#)$0=
Jestational age
Preterm 1#' 12 @)1 1)00
4erm $'1 $' 10)0 0)#%' 1)2# 90)>@A2)2$=
;aternal and family attributes
;aternal prepregnany :;!
+ormal and low 9<2#)'= ##' 2@ >)2 1)00
O,erweight 92$A2')'= 111 1> 1#)# 0)00$ 2)&1 91)&0A#)12=
Obese 9&0= 121 22 1@)2 <0)001 2)'2 91)%&A#)'1=
Cmo6ing during 1st trimester
0 igarette #$# #& ')$ 1)00
1A12 igarette 9>1A@$th perentile= 1%' 2& 12)@ 0)20' 1)&> 90)@#A2)1@=
1& igarette 9>@$th perentile= 10% $ #)% 0)12$ 0)#' 90)20A1)22=
;aternal eduation
12th grade 2&' 1% %)1 1)00
<12th grade ##$ $& 11)' 0)0$# 1)>% 90)''A2)@&=
;aternal age 9years=
1' >22 ># 10)& 1)00
<1' 11@ % $)' 0)1$& 1)%& 90)@2A&)>'=
0ae
7hite 1%0 1& %)> 1)00
:la6 $%0 $@ 10)2 0)&&2 0)%$ 90)#2A1)&#=
+umber of hildren at home
2 &$& #$ 12)% 0)00% 1)@@ 91)1'A2)'@=
>2 &@# 2> >)@ 1)00
+umber of adults at home
1 &0# 2% @)' 1)00
2 &2# &1 ')> 0)%%> 1)0@ 90)>>A1)%>=
& 10' 1& 11)' 0)&$# 1)&# 90)%2A2)$1=
Home sreening Guestionnaire sore
AdeGuate 9>#1= 1>0 1@ 11)& 1)00
5ess than adeGuate 9#1= $@0 $& ')1 0)>$ 1)2& 90)%#A2)0#=
CelfDemployed
Mes &%# #0 10)% 1)00
+o 2&@ 20 @)# 0)&$# 0)%' 90)#%A1)&1=
Kood stamp
+o 2$$ 2> 10)2 1)00
Mes &%0 &0 @)1 0)&% 0)@ 90)#@A1)&1=
7!C
+o ##& #1 ')& 1)00
Mes '# 11 11)% 0)#># 1)2> 90)>@A2)&%=
Alohol inta6e during pregnany
+o &'@ #% 11)@ 1)00
Mes 1@> 1@ ')% 0)##@ 0)@2 90)#'A1)&%=
C!( onfidene inter,al, 00( ris6 ratio1

based on gestational age and rae speifi birth weight perentiles for 8C population)
> Journal of Obesity
4A:52 &( ;ulti,ariable model showing ad.usted ris6 ratio for
materDnal and early hildhood determinants of obesity 9'$th
perentile= at the age of $ in Alabama n = >%@

)
Variables
Ad.usted 00

P
9'$? C!=
;aternal prepregnany :;!
+ormal and low 9<2#)'= 1)00
O,erweight 92$A2')'= 2)& 91)2'A#)11= 0)00$
Obese 9>&0= 2)$& 91)#'A#)&1= <0)001
:irth weight 9Lg=

@$th perentile 1)00

>@$th perentile 2)0# 91)1&A&)>@= 0)01@
+umber of hildren at home
2 9<median= 1)># 91)01A2)>#= 0)0#&
>2 9median= 1)00
Ce<
;ale 1)00
Kemale 1)>% 91)0$A2)>>= 0)0&1
Cmo6ing during 1st trimester

0 igarette 1)00
1A12 igarette 9>1A@$th perentile= 1)#2 90)@@A2)&= 0)1$2
1& igarette 9>@$th perentile= 0)$& 90)22A1)2%= 0)1$#
C!( onfidene inter,al)

Ad.usted ris6 ratio omputed using poisson regression model with robust
,ariane estimation)

:ased on gestational age and rae speifi birth weight perentiles for
8C population)

Cigarettes smo6ed per day)

body siIe E#&F) !t is belie,ed that AfrianDAmerian men
prefer the women to ha,e a fuller figure E##F) Howe,er, among
younger AfrianDAmerian hildren, a higher preD,alene of
obesity among females suggests that both bioDlogial as well
as beha,ioral mehanisms are in play) !f the beha,ioral
mehanism of soial aeptane of a fuller body siIe 9imposed
by parents*aregi,ers= plays an early role, it an e<plain the
higher li6elihood of obesity among AfriDanDAmerian girls)
How body siIe pereptions play into hildDhood obesity at age
$ when hildren may not ha,e any strong pereption about
their body image, and whether parentsB pereption of their
female hildBs fuller body siIe also transDlates into obesity
among girls, needs to be in,estigated)
An assoiation between birth weight and obesity during
hildhood has been reported, but results ha,e been inonsisD
tent E1%, 1@, &%, #$, #>F) !n our study, this assoiation was
signifiant in the presene of other fators suh as the number
of hildren at home, prepregnany :;!, and hild gender)
High birth weight helps to identify hildren who will be at a
higher ris6 of obesity and thus pro,ides an opporDtunity for
modifying their feeding and eating beha,iors and ontrolling
weight gain from an early stage)
Ha,ing fewer hildren at home was also assoiated with
obesity among hildren) !f there are fewer hildren at home,
they usually reei,e more attention and hene parents may
4A:52 #( ;ulti,ariable model showing ad.usted ris6 ratio for
materDnal and early hildhood determinants of o,erweight 9@$th to
<'$th perentile= at the age of $ in Alabama n = >@1

)
Variables
Ad.usted 00

P
9'$? C!=
;aternal prepregnany :;!
+ormal and low 9<2#)'= 1)00
O,erweight 92$A2')'= 1)'91)&#A2)%= <0)001
Obese 9>&0= 1)@@91)&&A2)>$= <0)001
:irth weight 9Lg=
@$th perentile
>@$th perentile 1)'#91)&&A2)@&= <0)001
Ce<
;ale 1)00
Kemale 1)2% 90)'>A1)%= 0)0''
Cmo6ing during 1st trimester

0 igarette 1)00
1A12 igarette 9>1A@$th perentile= 1)#091)02A1)'1= 0)0&$
1& igarette 9>@$th perentile= 0)'@90)>&A1)$#= 0)'&%
C!( onfidene inter,al)

Ad.usted ris6 ratio omputed using poisson regression model with robust
,ariane estimation)

:ased on gestational age and rae speifi birth weight perentiles for
8C population)

Cigarettes smo6ed per day)

indulge in o,erfeeding) O,erfeeding hildren has been
reporDted in AfrianDAmerians with parental pereption of
the hild being thin E21, #%F) A pre,ious study in an Afrian
Amerian population has also reported that the first born
hild was at a higher ris6 of beoming o,erweight E1@F)
Other studies ha,e also reported that being a first born hild
and ha,ing fewer hildren at home were ris6 fators for
hildhood obesity E1%, #@F)
!n our study, smo6ing 1A12 igarettes per day in the first
trimester inreased the ris6 of o,erweight and obesity among
hildren ompared to hildren of mothers who did not smo6e)
;any studiesNinluding a metaDanalysisNha,e reported that
hildren e<posed to smo6ing during pregnany are more li6ely
to beome o,erweight at age $ or later E1%, 20, 21, &&, &%, #'A
$2F) Cuggested mehanisms inlude the biologial eet of
smo6ing, priming the de,eloping brain to later obesity, or an
unhealthy postnatal home en,ironment E$&A$>F) Animal
models also indiate an obesogeni eet of smo6ing during
pregnany E$%, $@F) Prenatal niotine e<poDsure redues birth
weight, but the ospring beome hea,ier later in life E$%, $@F)
!n our study, a higher freGueny of smo6Ding was not
assoiated with inreased ris6) 4his finding is in agreement
with the biologi hypothesis and epidemiologi data
suggesting that early growth retardation is assoiated with
later obesity E$$, $>, $'A>2F) Howe,er, the age at whih the
shift from growth restrition to o,erweight*obesity hapDpens
by dose of smo6ing 9duration*freGueny= is not onsisDtent
aross studies) 4his may be related to methodologial
dierenes or dierene in other preD*postnatal e<posures
9geneti*en,ironmental= aross studies) !n summary, our
Journal of Obesity
results indiate that smo6ing during pregnany is
assoiated with inreased ris6 of obesity or o,erweight at
age $) Hene, redution or elimination of smo6ing during
pregnany ould promote healthy weight among hildren)
Assoiation of lower soioeonomi status with o,erD
weight has been reported by ,arious studies of white
populations) Howe,er, limited studies of AfrianDAmerian
population did not find any positi,e assoiation of lower
soioeonomi status and obesity E1@, #@F)
Pre,ious studies ha,e omputed odds ratios as a pro<y for
ris6 ratio for e,aluating the strength of assoiation between
ris6 fators and o,erweight among hildren) 7hen the outD
ome ourrene is ommon suh as obesity*o,erweight
9inidene > 10?=, odds ratios do not appro<imate ris6 ratio
E>&F) Kurthermore, odds ratios are ommonly but wrongly
interpreted as ris6 ratio E1#F) Hene, it is suggested that ris6
ratio is a more desirable measure of eet in prospeti,e
in,estigations E>&F) A uniGue strength of the study was its
prospeti,e data olletion that redued the possibility of
seletion and reall bias) Anthropometri measurements were
performed under standardiIed measurement protool)
Cmo6ing was based on selfDreport and it has been sugD
gested that women tend to underreport the number of igaD
rettes they smo6e during pregnany, leading to mislassifiaD
tion of those who indulge in lowDintensity smo6ing to nonD
smo6er or ,eryDlowDdegree smo6ing ategories E>#F) !f this
mislassifiation ourred, this may ha,e led to an underD
estimation of eet) !n suh irumstanes, true ris6 will be
higher than urrently reported in the study) Howe,er, studDies
ha,e reported that selfDreporting of smo6ing during pregD
nany has shown reasonable ,alidity E>$F) !nformation was
missing for some ,ariables at later followup, thus pre,enting
utiliIation of the entire sample) Howe,er, there was no
dierene in outome between those who ontributed data in
the final model and those who did not) !n this study, we did not
ha,e enough power to assess dierentials in o,erweight and
obesity by rae)
20 Concl&sion
Children of o,erweight and obese mothers, and those with
higher birth weights, are more li6ely to be o,erweight at age $)
Jirls are at a higher ris6 of being o,erweight at age $) Kurther
in,estigation of the aregi,er*parental perepDtion of a larger
body siIe being more soially desirable and the eating*feeding
beha,iors of parents an pro,ide ,aluable information about
biologial ,ersus en,ironmental origins of o,erweight among
girls) 4he assoiation of high prepregDnany :;! and obesity
substantiates earlier findings and indiates that inter,entions
direted at pre,ention of hildDhood obesity should ome into
play early on, targeting preDpregnany :;!) Cmo6ing 1A12
igarettes per day during the first trimester was assoiated with
inreased ris6 of hildhood o,erweight and obesity, while high
freGueny of smo6ing 91& igarettes*day= was not assoiated
with inreased obeDsity) 7hether it is the unhealthy diet
beha,ior of parents who smo6e or fetal programming due to
e<posure in utero, needs to be in,estigated further)
%
Conflict of Interests
4he authors delare that they ha,e no onflit of interests)
!cknowledgment
4his wor6 is supported through grant nos) +O1DH"D#2@11
and P0PD'0D11 from the +ational !nstitute of Child Health
and "e,elopment)
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