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METHODS
We analyzed data from the Pregnancy Risk
Assessment Monitoring System (PRAMS), an
ongoing population-based surveillance system
that collects information on self-reported maternal characteristics before, during, and after
pregnancy in participating states. Each month,
a stratified systematic sample of approximately
150 mothers is selected from the birth certificate records of each state. To participate in
PRAMS, women must be state residents who
have recently delivered a live-born infant,
typically in the preceding 3 or 4 months.
A self-administered, 14-page questionnaire is
mailed to each eligible mother. If the mother
fails to respond, a second or third questionnaire
is sent to her. If there is no response to these
additional mailings, attempts are made to reach
the mother for a telephone interview. Each
mothers self-reported survey data are linked
back to her childs birth certificate record; only
selected birth certificate variables are included
in the final PRAMS data set. Currently, 37
Maternal Characteristics
We used birth certificate information to
analyze data on maternal characteristics such
Data Analysis
We excluded the following women from the
analysis: those who reported on PRAMS that
RESULTS
Demographic characteristics of the PRAMS
population in each of the 7 states are described
in Table 1. The overall GDM prevalence was
4.0% (SE = 0.2), with a range from 3.1%
(SE = 0.4) in Florida to 5.0% (SE = 0.7) in Ohio
(Table 1). For all states combined, GDM prevalence estimates by BMI category were as
follows: underweight, 0.7% (SE = 0.3); normal
weight, 2.3% (SE = 0.3); overweight, 4.8%
(SE = 0.5); obese, 5.5% (SE = 0.7); and extremely obese, 11.5% (SE =1.3; Table 2).
In addition, we found that 0.9% (SE = 0.4) of
women with gestational diabetes were underweight, 28.4% (SE = 2.8) were of normal
weight, 28.5% (SE = 2.7) were overweight,
16.2% (SE = 2.1) were obese, and 26.0%
(SE = 2.7) were extremely obese. The probability of GDM increased with increasing BMI,
although the confidence bands became quite
wide when BMIs exceeded 40 kg/m2 (Figure 1).
There was no clear BMI threshold below which
a doseresponse relationship was not evident.
Because none of the potential confounders
changed ORs by 10% or more, we included in
our adjusted model covariates that have been
found in the literature to be associated with
both the exposure (BMI) and the outcome
(GDM). When the normal-weight BMI category
was used as a reference group, we found that
the unadjusted RRs of developing GDM were
0.3 (95% CI = 0.1, 0.7) for underweight
women, 2.1 (95% CI =1.6, 2.9) for overweight
women, 2.4 (95% CI =1.7, 3.4) for obese
women, and 5.0 (95% CI = 3.6, 6.9) for extremely obese women. RRs did not change
after adjustment for maternal age, race/ethnicity, marital status, and parity (Table 3).
The overall adjusted PAF due to overweight
and obesity was 46.2% (95% CI = 36.1, 56.3;
Table 2). Adjusted percentages of GDM individually attributable to overweight, obesity,
and extreme obesity were 15.4% (95%
TABLE 1Sample-Weighted Demographic Characteristics: Pregnancy Risk Assessment Monitoring System, 7 US States, 20042006
Total
(20042006),
% (SE)
Florida
(20042005),
% (SE)
Nebraska
(20052006),
% (SE)
New Yorka
(20042006),
% (SE)
Ohio
(2006),
% (SE)
South Carolina
(20042006),
% (SE)
Vermont
(20042006),
% (SE)
Washington
(20042006),
% (SE)
< 20
2034
10.4 (0.3)
74.7 (0.5)
11.0 (0.1)
74.9 (0.8)
7.4 (0.5)
80.2 (0.8)
7.5 (0.7)
70.7 (1.1)
12.0 (1.2)
75.5 (1.5)
13.3 (0.9)
76.2 (1.1)
7.1 (0.5)
75.7 (0.8)
9.0 (0.6)
76.2 (0.9)
35
14.9 (0.4)
14.1 (0.8)
12.4 (0.7)
21.7 (1.0)
12.5 (1.1)
10.5 (0.8)
17.1 (0.7)
14.8 (0.7)
< 12
18.2 (0.5)
20.4 (0.8)
14.9 (0.6)
16.2 (1.0)
15.7 (1.3)
23.0 (1.2)
9.3 (0.6)
17.4 (0.7)
12
27.9 (0.6)
32.4 (1.0)
21.1 (0.9)
23.1 (1.0)
28.4 (1.6)
26.0 (1.2)
32.1 (0.9)
24.5 (0.9)
> 12
53.9 (0.6)
47.2 (1.1)
64.1 (0.9)
60.7 (1.2)
55.9 (1.7)
50.9 (1.3)
58.6 (0.9)
58.1 (1.0)
Hispanic
Non-Hispanic White
15.6 (0.4)
63.9 (0.5)
27.1 (1.0)
48.2 (1.0)
14.0 (0.1)
75.5 (0.2)
13.1 (0.9)
74.5 (1.1)
3.3 (0.7)
77.3 (1.0)
7.4 (0.7)
58.3 (1.3)
NA
100.0
17.5 (0.1)
64.9 (0.4)
Non-Hispanic Black
15.2 (0.2)
20.1 (0.5)
5.5 (0.1)
7.9 (0.7)
14.8 (0.2)
31.9 (1.3)
NA
3.2 (0.1)
5.3 (0.3)
4.7 (0.5)
4.9 (0.2)
4.5 (0.5)
4.6 (0.8)
2.4 (0.4)
NA
14.4 (0.4)
Yes
61.9 (0.6)
58.2 (1.0)
71.1 (0.9)
67.0 (1.2)
60.1 (1.7)
56.9 (1.3)
68.8 (0.9)
69.6 (0.9)
No
38.1 (0.6)
41.8 (1.0)
28.9 (0.9)
33.0 (1.2)
39.9 (1.7)
43.1 (1.3)
31.2 (0.9)
30.4 (0.9)
45.9 (0.6)
54.1 (0.6)
51.2 (1.1)
48.8 (1.1)
40.9 (1.0)
59.1 (1.0)
35.5 (1.2)
64.5 (1.2)
41.7 (1.7)
58.3 (1.7)
58.1 (1.3)
41.9 (1.3)
42.1 (0.9)
57.9 (0.9)
49.2 (1.0)
50.8 (1.0)
Yes
55.7 (0.6)
52.1 (1.1)
63.3 (0.9)
62.4 (1.2)
58.1 (1.7)
45.0 (1.3)
59.2 (0.9)
55.9 (1.0)
No
44.3 (0.6)
47.9 (1.1)
36.7 (0.9)
37.6 (1.2)
41.9 (1.7)
55.0 (1.3)
40.8 (0.9)
44.1 (1.0)
Maternal Characteristic
Age, y
Education, y
Race/ethnicityb
Other
Married
Medicaid recipient
Yes
No
WIC recipient
Parity
0
42.1 (0.6)
43.3 (1.1)
36.7 (1.0)
41.6 (1.2)
41.0 (1.7)
42.4 (1.3)
44.8 (0.9)
42.9 (1.0)
12
47.9 (0.6)
46.8 (1.1)
50.8 (1.1)
49.1 (1.2)
47.3 (1.8)
50.3 (1.3)
48.2 (0.9)
47.0 (1.1)
10.0 (0.4)
9.8 (0.7)
12.5 (0.7)
9.3 (0.7)
11.7 (1.1)
7.3 (0.7)
6.9 (0.5)
10.1 (0.6)
>2
Smoking status
Smokerc
13.4 (0.4)
9.1 (0.7)
15.8 (0.8)
15.5 (0.9)
17.4 (1.3)
15.6 (1.0)
18.3 (0.7)
11.5 (0.7)
Nonsmoker
86.6 (0.4)
90.9 (0.7)
84.2 (0.8)
84.5 (0.9)
82.6 (1.3)
84.4 (1.0)
81.7 (0.7)
88.5 (0.7)
4.8 (0.3)
6.1 (0.5)
4.2 (0.4)
3.3 (0.4)
5.1 (0.8)
4.7 (0.6)
3.2 (0.3)
3.0 (0.3)
50.3 (0.6)
53.8 (1.1)
50.3 (1.1)
50.4 (1.2)
48.0 (1.7)
44.1 (1.3)
50.5 (0.9)
49.0 (1.0)
Overweight (2529.9)
23.8 (0.5)
22.1 (0.9)
24.5 (0.9)
24.3 (1.0)
24.2 (1.5)
25.3 (1.2)
24.1 (0.8)
26.4 (0.9)
Obese (3034.9)
Extremely obese (3564.9)
11.9 (0.4)
9.2 (0.4)
10.5 (0.7)
7.6 (0.6)
13.0 (0.7)
7.9 (0.6)
12.3 (0.8)
9.7 (0.7)
12.3 (1.2)
10.4 (1.0)
14.7 (0.9)
11.2 (0.8)
12.2 (0.6)
10.1 (0.6)
12.0 (0.7)
9.5 (0.6)
GDM
Yes
4.0 (0.2)
3.1 (0.4)
4.0 (0.4)
3.8 (0.4)
5.0 (0.7)
4.9 (0.6)
3.4 (0.3)
4.8 (0.4)
No
96.0 (0.2)
96.9 (0.4)
96.0 (0.4)
96.2 (0.4)
95.0 (0.7)
95.1 (0.6)
96.6 (0.3)
95.2 (0.4)
Note. BMI = body mass index; GDM = gestational diabetes mellitus; NA = not applicable; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children. The total sample size was
N = 22767; for Florida, n = 4053; for Nebraska, n = 3411; for New York, n = 2744; for Ohio, n = 1497; for South Carolina, n = 3848; for Vermont, n = 3097; for Washington, n = 4117. Overall and state
sample sizes are unweighted.
a
Excludes New York City.
b
Only non-Hispanic White women were included in analyses of Vermont data.
c
Defined as smoking during the final 3 months of pregnancy (self-reported in PRAMS) or during the third trimester (reported on birth certificates).
TABLE 2Sample-Weighted
Gestational Diabetes Mellitus (GDM)
Prevalence, by Demographic
Characteristics: Pregnancy Risk
Assessment Monitoring System, 7 US
States, 20042006
Maternal Characteristic
Overall
GDM Prevalence,
% (SE)
4.0 (0.2)
Age, y
< 20
1.0 (0.3)
2034
3.6 (0.3)
35
8.4 (0.9)
Education, y
< 12
12
2.8 (0.4)
3.9 (0.5)
> 12
4.5 (0.3)
Race/ethnicitya
Hispanic
4.4 (0.6)
Non-Hispanic White
4.0 (0.3)
Non-Hispanic Black
3.6 (0.4)
Other
5.4 (1.0)
Married
Yes
4.6 (0.3)
No
3.1 (0.3)
Medicaid recipient
Yes
3.4 (0.3)
No
4.6 (0.4)
WIC recipient
Yes
4.3 (0.4)
No
Parity
3.7 (0.3)
DISCUSSION
3.0 (0.3)
12
4.8 (0.4)
>2
5.0 (0.9)
Smoking status
Smokerb
3.7 (0.6)
Nonsmoker
4.1 (0.3)
0.7 (0.3)
2.3 (0.3)
Overweight (2529.9)
4.8 (0.5)
Obese (3034.9)
Extremely obese (3564.9)
5.5 (0.7)
11.5 (1.4)
Note. BMI = body mass index; WIC = Special Supplemental Nutrition Program for Women, Infants, and
Children.
a
Only non-Hispanic White women were included in
analyses of Vermont data.
b
Defined as smoking during the final 3 months of
pregnancy (self-reported in PRAMS) or during the third
trimester (reported on birth certificates).
RR (95% CI)
Unadjusted
Adjusteda
...
...
1.00
1.00
...
...
...
...
Unadjusted
Adjusteda
Conclusions
Note. BMI = body mass index; CI = confidence interval; PAF = population-attributable fraction; RR = relative risk. The sample
size used for unadjusted RR was n = 22 767; for adjusted RR, n = 22 200.
a
Adjusted models included covariates for maternal age, race/ethnicity, marital status, and parity.
b
We interpreted each PAF estimate to be the reduction in disease prevalence that would be expected to occur if all women in
the overweight or obese BMI categories had a GDM risk equivalent to that of women in the normal BMI category, assuming
that the risk for GDM among those with a low or normal BMI remained unchanged.
reduce diabetes-related adverse pregnancy outcomes. Sustaining this weight loss beyond pregnancy should reduce womens future risk for
type 2 diabetes.30
Limitations
To our knowledge, our study provides the
first population-based estimates of the contribution of overweight and obesity to GDM.
However, the study involves some limitations.
Prepregnancy weight is self-reported in PRAMS
and is likely to be self-reported on birth
certificates; estimates of obesity prevalence
based on self-reported weight tend to be lower
than those based on measured data.31 Therefore, we may have underestimated the prevalence of prepregnancy overweight and obesity,
which could have resulted in an underestimation
of the contribution of overweight and obesity to
the PAF assuming that the BMI misclassification
was nondifferential.
In addition, because PRAMS collects data
only on women who have delivered a live-born
infant, our analysis did not include women
whose pregnancies ended in a miscarriage, fetal
death, or stillbirth. However, GDM typically
develops in the late second or early third
trimester of pregnancy, and only a small proportion of women (6.3 per 1000 women)
experience fetal loss after 20 weeks. Therefore,
our estimates of GDM prevalence should not
have been substantially affected by the restriction of our analysis to live births.
A large percentage of GDM cases are potentially attributable to overweight and obesity
and could be avoided by preventing these
conditions. Data such as ours can help public
health officials estimate the potential effects of
prevention interventions on GDM prevalence
rates. Lifestyle interventions designed to reduce BMIs have the potential to lower GDM
risk. Therefore, public health efforts to promote
recommended levels of physical activity and
healthy eating habits among women of reproductive age should be intensified. j
Contributors
S. Y. Kim and L. England originated the study. S. Y. Kim
analyzed the data, led the writing, and supervised all
aspects of study implementation. L. England, C. Bish,
G. A. Satten, and P. Dietz synthesized the analysis. H. G.
Wilson analyzed the data and synthesized the analysis.
All of the authors helped conceptualize ideas, interpret
findings, and review drafts of the article.
Acknowledgments
We thank Brian Morrow for his technical expertise and
consultation. Data from the Pregnancy Risk Assessment
Monitoring System (PRAMS) included in this study were
collected at the state level by the following state working
group collaborators and their staff: Albert Woolbright
(Alabama), Kathy Perham-Hester (Alaska), Mary McGehee
(Arkansas), Alyson Shupe (Colorado), Charlon Kroelinger
(Delaware), Jamie Fairclough (Florida), Carol Hoban
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