doi:10.1111/jpc.

14274

ORIGINAL ARTICLE

Association of maternal pre-pregnancy body mass index and

gestational weight gain with Chinese infant growth
Weiwei Zhang, Fenghai Niu and Xueyun Ren
Department of Pediatrics, Affiliated Hospital of Jining Medical University, Jining, China

Aim: To evaluate the association of maternal pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) with offspring growth
from birth to 12 months in China.
Methods: A retrospective cohort of 3764 mother–child dyads, with children born between June 2014 and June 2016, was identified in an elec-
tronic medical record database. Maternal pre-pregnancy body weight and height measurements throughout pregnancy were extracted, and body
weights and lengths of their children had been measured at birth, 3, 6, 9 and 12 months. The association between maternal pre-pregnancy BMI
and GWG and offspring growth was evaluated using repeated-measure general linear models and post hoc tests.
Results: Both pre-pregnancy BMI and GWG were significantly associated with the Z-scores for weight and for length during the first year of
age. Moreover, their interactions were associated with a greater risk of overweight/obesity of offspring in early infancy after controlling for poten-
tial confounding factors. Defined by the Institute of Medicine guidelines, excessive GWG, especially during the first trimester, was associated with
an increased risk of offspring overweight or obesity at 12 months old in all maternal pre-pregnancy BMI categories.
Conclusion: Maintenance of appropriate body weight before and during pregnancy, especially during the first trimester, is crucial to prevent
paediatric obesity.

Key words: body mass index; gestational weight gain; obesity; overweight; post-natal infant growth; pregnancy.

What is already known on this topic What this paper adds

1 Institute of Medicine recommendations for gestational weight
gain (GWG) were defined according to World Health Organization
body mass index (BMI) cut-off values.
2 Maternal pre-pregnancy BMI and GWG have been reported to be
independently associated with early childhood growth in west-
ern populations.
1 Excessive GWG that was defined according to Chinese BMI clas-
sification standards increased the risk of Chinese infant adiposity
2 The interaction between pre-pregnancy BMI and GWG shapes
Chinese infant growth in the first year of life.
3 GWG in the first trimester contributed significantly to childhood
obesity.

Childhood obesity is now recognised as one of the most serious
public health concerns globally and is steadily affecting many
low- and middle-income countries, particularly in the urban set-
tings.1 According to the Global Burden of Disease in 2015,2 China
had the largest number of obese children world-wide, reaching
15 million. Childhood obesity is difficult to be reversed through
interventions and tends to persist into adulthood.3 Moreover, it
has been demonstrated to be associated with various adverse
physical (e.g. hypertension, type II diabetes and cardiovascular
diseases,), psychological (e.g. depression and low self-esteem)
and social outcomes (e.g. diminished quality of life).4,5 The pre-
vention of childhood obesity has become a global public health
priority.
Correspondence: Ms Xueyun Ren, Department of Pediatrics, Affiliated
Hospital of Jining Medical University, No. 89 Guhuai Road, Jining 272029,
China. Fax: +86 0537 2213030; email: renxueyunjn@163.com
Conflict of interest: None declared.
Accepted for publication 20 September 2018.
Recent studies have reported that infancy is a critical period in
child development. The Growing Up Today Study in the USA
demonstrated that each 1 kg increase in birthweight was associ-
ated with about a 5% increase in the chance of being overweight
in adolescence.6 In a large birth cohort study, 30.7% of infants
showed catch-up growth between 0 and 2 years, and these chil-
dren had greater body mass index (BMI), percentage fat mass
and waist circumference at 5 years old.7 Meanwhile, infant over-
weight status can be linked to their mothers’ pre-pregnancy BMI.
In 2009, the Institute of Medicine (IOM) highlighted both pre-
pregnancy BMI and excess gestational weight gain (GWG) as sig-
nificant contributors to infant development.8 Several studies have
reported significantly increased odds ratios for offspring obesity in
obese mothers, ranging from 3.1 among low-income US chil-
dren9 to above 5 for US children born between 1980 and 1990.10
Two recent meta-analyses suggested that excessive GWG was
associated with a higher risk of offspring obesity throughout
life.11,12 However, the effect of interaction of pre-pregnancy BMI
and maternal GWG on the shape of infant growth has been
rarely studied, especially in China.

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Effect of BMI and GWG on infant growth W Zhang et al.

The aim of the present study was to evaluate the association of
maternal pre-pregnancy BMI and GWG with offspring growth
from birth to 12 months in China.
Methods
Study population
This study assembled a retrospective cohort comprised of maternal–
child dyads that were identified in the electronic medical record
(EMR). All children were born between June 2014 and June
2016 at the Department of Pediatrics, Affiliated Hospital of Jining
Medical University, China. All dyads received medical care
throughout pregnancy and the first year of the child’s life. The pro-
cedures involving human subjects were approved by the review
boards of the Affiliated Hospital of Jining Medical University.
Pregnant women’s health records include general information
(age, numbers of pregnancy/infants and smoking habits), clinical
measurements (height, weight, blood pressure, gynaecological
examinations, etc.), complications during pregnancy, pregnancy
outcomes (delivery modes and labour complications) and post-
natal period examinations (<42 days after delivery). Children’s
health records include information from newborns (date of birth,
gender, gestational week of birth, birthweight, birth recumbent
length and Apgar score) to infancy (health examinations every
3 months for the first 12 months).

Table 1 Characteristics of participants classified by pre-pregnancy body mass index (BMI)

Characteristics Pre-pregnancy BMI† P value for

trend
Underweight Normal weight Overweight Obesity

No. of participants, n (%) 387 (10.3) 2425 (64.4) 714 (19.0) 238 (6.3)
Maternal characteristics
Maternal age at delivery, years, mean (SD) 26.8 (3.0) 26.9 (2.9) 27.0 (3.3) 27.5 (3.4) 0.46
Pre-pregnancy BMI, kg/m2, mean (SD) 17.9 (1.0) 21.5 (1.4) 26.1 (1.4) 30.3 (1.6) <0.01‡
Gestational weight gain, kg, mean (SD) 17.9 (5.9) 17.1 (5.7) 16.8 (5.2) 15.8 (4.9) <0.01‡
First-trimester weight gain, g/week, mean (SD) 228.1 (257.2) 192.2 (243.1) 175.6 (244.7) 132.4 (253.2) <0.01‡
Second- and third-trimester weight gain, g/week, mean (SD) 467.2 (239.2) 461.8 (199.5) 450.1 (194.5) 396.8 (206.8) <0.01‡
Parity, n (%)
Primiparous 311 (80.4) 1893 (78.1) 564 (79.0) 182 (76.5) 0.63
Multiparous 76 (19.6) 532 (21.9) 150 (21.0) 56 (23.5)
Cigarette exposure during pregnancy, n (%)
No 285 (73.6) 1748 (72.1) 524 (73.4) 166 (69.7) 0.66
Yes 102 (26.3) 677 (27.9) 190 (26.6) 72 (30.3)
Hypertensive disorders in pregnancy, n (%)
No 279 (97.9) 2357 (97.2) 690 (96.6) 229 (96.2) 0.76
Yes 8 (2.1) 68 (2.8) 24 (3.4) 9 (3.8)
Delivery mode, n (%)
Vaginal delivery 176 (45.5) 945 (39.0) 217 (30.4) 51 (21.4) <0.01‡
Caesarean section 211 (54.5) 1480 (61.0) 497 (69.6) 187 (78.6)
Child characteristics
Gestational age at delivery, weeks, mean (SD) 39.1 (1.2) 39.2 (1.1) 39.3 (1.1) 39.2 (1.2) 0.61
Gender, n (%)
Male 197 (50.9) 1261 (52.0) 368 (51.5) 127 (53.4) 0.94
Female 190 (49.1) 1164 (48.0) 346 (48.5) 111 (46.6)
Mode of infant feeding, n (%)
Exclusive breastfeeding 82 (21.2) 543 (22.4) 149 (20.9) 41 (17.2) 0.67
Mixed breast and formula 289 (74.7) 1787 (73.7) 534 (74.8) 187 (78.6)
Exclusive formula feeding 16 (4.1) 95 (3.9) 31 (4.3) 10 (4.2)
Weight, kg, mean (SD)
Birth 3.2 (0.4) 3.4 (0.5) 3.5 (0.5) 3.7 (0.5) <0.01‡
3 months 6.5 (0.7) 6.8 (0.8) 6.9 (0.8) 7.1 (0.9) <0.01‡
6 months 8.2 (1.0) 8.6 (1.0) 8.7 (1.0) 8.9 (1.1) <0.01‡
9 months 9.1 (1.1) 9.6 (1.1) 9.8 (1.1) 10.0 (1.2) <0.01‡
12 months 10.1 (1.2) 10.4 (1.1) 10.7 (1.2) 10.9 (1.2) <0.01‡
Overweight at age 12 months, n (%)§ 116 (30.1) 955 (39.4) 326 (45.6) 118 (49.7) <0.01‡
Obesity at age 12 months, n (%)§ 44 (11.4) 420 (17.3) 154 (21.6) 63 (26.6) <0.01‡

†BMI (kg/m2): Underweight (<18.5), normal weight (18.5–23.9), overweight (24–27.9) and obesity (≥28.0). ‡Significant differences among underweight, nor-
mal weight, overweight and obesity groups. §Overweight was defined as weight for length ≥85th percentile; obesity was defined as weight for length ≥95th
percentile; gender-specific weight-for-length percentiles were based on World Health Organization growth reference.15 SD, standard deviation.

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Table 2 Characteristics of participants classified by gestational weight gain (GWG)

Characteristics Gestational weight gain IOM categories† P value for trend

Inadequate Adequate Excessive

No. of participants, n (%) 718 (19.1) 1176 (31.2) 1870 (49.7)

Maternal characteristics
Maternal age at delivery, years, mean (SD) 27.6 (3.3) 27.1 (3.2) 26.9 (3.3) <0.01‡
Pre-pregnancy BMI, kg/m2, mean (SD) 21.2 (2.3) 22.1 (2.2) 23.4 (3.1) <0.01‡
Gestational weight gain, kg, mean (SD) 8.9 (2.2) 14.1 (2.0) 20.2 (4.9) <0.01‡
First-trimester weight gain, g/week, mean (SD) 139.1 (208.5) 163.8 (197.5) 256.7 (261.8) <0.01‡
Second- and third-trimester weight gain, g/week, mean (SD) 256.4 (152.3) 453.2 (176.3) 581 (221.2) <0.01‡
Parity, n (%)
Primiparous 579 (80.6) 934 (79.4) 1457 (77.9) 0.27
Multiparous 139 (19.4) 242 (20.6) 413 (22.1)
Cigarette exposure during pregnancy, n (%)
No 510 (71.0) 841 (71.5) 1372 (73.3) 0.37
Yes 208 (29.0) 335 (28.5) 498 (26.7)
Hypertensive disorders in pregnancy, n (%)
No 702 (97.8) 1138 (96.8) 1823 (97.5) 0.35
Yes 16 (2.2) 38 (3.2) 47 (2.5)
Delivery mode, n (%)
Vaginal delivery 344 (47.9) 527 (44.8) 677 (36.2) <0.01‡
Caesarean section 374 (52.1) 649 (55.2) 1193 (63.8)
Child characteristics
Gestational age at delivery, weeks, mean (SD) 39.1 (1.1) 39.2 (1.2) 39.2 (1.2) 0.72
Gender, n (%)
Male 369 (51.4) 611 (52.0) 973 (52.0) 0.96
Female 349 (48.6) 565 (48.0) 897 (48.0)
Mode of infant feeding, n (%)
Exclusive breastfeeding 148 (20.6) 254 (21.6) 413 (22.1) 0.91
Mixed breast and formula 538 (74.9) 875 (74.4) 1384 (74.0)
Exclusive formula feeding 32 (4.5) 47 (4.0) 73 (3.9)
Weight, kg, mean (SD)
Birth 3.2 (0.4) 3.3 (0.5) 3.5 (0.5) <0.01‡
3 months 6.5 (0.7) 6.6 (0.8) 6.9 (0.8) <0.01‡
6 months 8.2 (1.0) 8.5 (1.0) 8.7 (1.1) <0.01‡
9 months 9.1 (1.1) 9.5 (1.1) 9.8 (1.2) <0.01‡
12 months 10.0 (1.1) 10.3 (1.2) 10.7 (1.2) <0.01‡
Overweight at age 12 months, n (%)§ 233 (32.4) 436 (37.1) 847 (45.3) <0.01‡
Obesity at age 12 months, n (%)§ 92 (12.8) 194 (16.5) 395 (21.1) <0.01‡

†Institute of Medicine (IOM) categories: Inadequate: <12.5 kg (pre-pregnancy body mass index (BMI) <18.5 kg/m2), <11.5 kg (BMI 18.5–23.9 kg/m2),
<7 kg (BMI 24.0–27.9 kg/m2) and <5 kg (BMI >28 kg/m2); adequate: 12.5–18 kg (BMI <18.5 kg/m2), 11.5–16 kg (BMI 18.5–23.9 kg/m2), 7–11.5 kg (BMI
24.0–27.9 kg/m2) and 5–9 kg (BMI >28 kg/m2); and excessive: >18 kg (BMI <18.5 kg/m2), >16 kg (BMI 18.5–23.9 kg/m2), >11.5 kg (BMI 24.0–27.9 kg/m2)
and >9 kg (BMI >28 kg/m2) according to the Chinese maternal pre-pregnancy BMI classification standard and the 2009 IOM GWG recommendations.
‡Significant differences among inadequate, adequate and excessive groups. §Overweight was defined as weight for length ≥85th percentile; obesity
was defined as weight for length ≥95th percentile; gender-specific weight-for-length percentiles were based on World Health Organization growth
reference.15 SD, standard deviation.

Inclusion and exclusion criteria
Mothers were eligible if they were at least 18 years old when
their children were delivered and had height and weight records
in the EMR within 365 days prior to the estimated date of con-
ception. Children were eligible if they were at least 1 year old at
June 2017 and had at least three concurrent measurements of
child height and weight in the first year of life.
Maternal–child dyads were excluded if they met any of the fol-
lowing conditions: (i) multiple gestation; (ii) children with medical
conditions known to affect infant growth (e.g. hypothyroidism,
diabetes, heart diseases, Trisomy 21 and cancers); (iii) maternal
insulin use during pregnancy; and (iv) enrolment in another
clinical trial.
Maternal pre-pregnancy BMI and GWG
Pre-pregnancy BMI was calculated by dividing weight in kilo-
grams by the square of height in meters that were recorded
within 1 year of the estimated date of conception. Maternal pre-

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Effect of BMI and GWG on infant growth W Zhang et al.

Fig. 2 Probability for childhood overweight or obesity by trimester-

specific gestational weight gain (GWG) rate (g/week).

Total GWG was calculated as the difference between the

mothers’ delivery weight and her pre-pregnancy weight. GWG
was categorised as inadequate, adequate and excessive according
to the IOM recommendations.14 Adequate GWG was defined as
12.5–18, 11.5–16, 7–11.5 and 5–9 kg for underweight, normal
weight, overweight and obese women, respectively. The first and
the second and third trimesters’ GWG rates were calculated as
the difference between pre-pregnancy weight and weight as mea-
Fig. 1 Association of offspring’s Z-scores for weight for length at the sured at the first prenatal care visit and the difference between
age of 12 months with maternal pre-pregnancy body mass index (a) and the total and first trimester GWG, respectively. Then, the GWG
gestational weight gain (b). (a): ( ), Underweight; ( ), normal rates for different trimesters were calculated by dividing the
weight; ( ), overweight; ( ), obesity. (b): ( ), Inadequate; ( ), GWG by the corresponding gestational age.
adequate; ( ), excessive.

pregnancy BMI was divided into four categories based on the
standard of the Working Group on Obesity in China13: under-
weight BMI <18.5 kg/m2, normal weight (≥18.5–24 kg/m2),
overweight (≥24–28 kg/m2) and obesity (≥28 kg/m2).
Child anthropometry
Gender-specific and gestational age-adjusted weight-for-length
Z-scores were calculated at months 3, 6, 9 and 12 using the
World Health Organization (WHO) Child Growth Standards as a

Table 3 Relative risk and 95% confidence intervals of childhood overweight or obesity at age 12 months stratified by maternal pre-pregnancy body
mass index (BMI) and gestational weight gain (GWG)

Relative risk and 95% confidence interval

Underweight† Normal weight Overweight Obesity Total

Inadequate‡ 0.47 (0.39–0.58)§ 0.93 (0.84–1.05) 1.12 (0.79–1.56) 0.67 (0.28–1.17) 0.89 (0.81–0.96)§
Adequate 0.66 (0.33–1.03) 1.00 (reference) 1.04 (0.91–1.16) 1.23 (0.80–1.74) 1.00 (reference)
Excessive 0.78 (0.55–1.09) 1.23 (1.08–1.47)§ 1.51 (1.20–1.85)§ 1.72 (1.47–1.98)§ 1.47 (1.18–1.63)§
Total 0.61 (0.40–0.80)§ 1.00 (reference) 1.36 (1.19–1.53)§ 1.58 (1.16–1.96)§

†BMI (kg/m2): Underweight (<18.5), normal weight (18.5–23.9), overweight (24–27.9) and obesity (≥28.0). ‡Institute of Medicine (IOM) categories: Inade-
quate: <12.5 kg (pre-pregnancy BMI <18.5 kg/m2), <11.5 kg (BMI 18.5–23.9 kg/m2), <7 kg (BMI 24.0–27.9 kg/m2) and <5 kg (BMI >28 kg/m2); adequate:
12.5–18 kg (BMI <18.5 kg/m2), 11.5–16 kg (BMI 18.5–23.9 kg/m2), 7–11.5 kg (BMI 24.0–27.9 kg/m2) and 5–9 kg (BMI >28 kg/m2); and excessive: >18 kg
(BMI <18.5 kg/m2), >16 kg (BMI 18.5–23.9 kg/m2), >11.5 kg (BMI 24.0–27.9 kg/m2) and >9 kg (BMI >28 kg/m2) according to the Chinese maternal
pre-pregnancy BMI classification standard and the 2009 IOM GWG recommendations. Models were adjusted for maternal age, parity, smoking, hyperten-
sive disorders in pregnancy, delivery mode, gestational age at delivery, infant gender and mode of infant feeding. §Significant differences compared to
patients with normal maternal pre-pregnancy BMI and adequate GWG.

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W Zhang et al.
reference.15 Overweight was defined as a weight-for-length score
above the 85th percentile, and obesity was defined as a weight-
for-length score above the 95th percentile.
Statistical analysis
Continuous variables with normal distribution are presented as
means  SD and compared using the analysis of variance. All cat-
egorical variables were summarised and expressed as proportions
and compared with the use of the χ 2 test with normal approxi-
mation or Fisher’s exact test, as appropriate. Repeated-measure
general linear models and post hoc tests were used to evaluate the
main effects of maternal pre-pregnancy BMI, maternal GWG and
their interaction term on the infant growth trajectory, with
adjustments for covariates. All tests were two-sided, and a
P value of less than 0.05 was considered significant.
All statistical analyses were performed using the SPSS statisti-
cal software program package (SPSS, version 20.0 for Windows;
SPSS Inc., Chicago, IL, USA).
Results
A total of 3764 mother–child dyads met the inclusion and exclu-
sion criteria and were included in the analysis. The prevalence of
mothers who were underweight, normal weight, overweight and
obese before pregnancy were 10.3, 64.4, 19.0 and 6.3%, respec-
tively (Table 1). Women with inadequate, adequate and exces-
sive GWG accounted for 19.1, 31.2 and 49.7% of the total
population, respectively (Table 2). Baseline characteristics of both
mothers and children according to maternal pre-pregnancy BMI
and GWG are presented in Tables 1 and 2, respectively. There are
significant differences in the GWG among mothers with various
pre-pregnancy BMIs (P < 0.01). Post hoc analyses indicated that
the total GWG, first trimester weight gain and second and third
trimester weight gain were all significantly higher in pre-
pregnancy underweight mothers compared to obese mothers
(all P < 0.01).
Figure 1 displayed that offspring’s Z-scores for weight for
length were associated with maternal BMI (Fig. 1a) and GWG
(Fig. 1b) during the first year of life. After adjustment for mater-
nal age, parity, smoking, hypertensive disorders in pregnancy,
delivery mode, gestational age at delivery, infant gender and
mode of infant feeding, repeated-measure general linear models
and post hoc tests indicated that the differences in the Z-scores for
weight for length were significantly higher in infants born to
mothers with pre-pregnancy overweight or obesity compared
with those in infants born to mothers with pre-pregnancy normal
weight or underweight (P < 0.01). In addition, the offspring of
mothers with excessive GWG tended to have higher Z-scores for
weight for length than those of mothers with inadequate or ade-
quate GWG (P < 0.01).
Table 3 shows the relative risk (RR) of childhood overweight/
obesity at age 12 months stratified by maternal pre-pregnancy
BMI and GWG. After adjustment for all confounding factors, the
risk of childhood overweight/obesity at age 12 months was sig-
nificantly higher in infants born to mothers with pre-pregnancy
overweight (RR = 1.36, 95% confidence interval (CI): 1.19–1.53,
P < 0.01) or obesity (RR = 1.58, 95% CI: 1.16–1.96, P < 0.01)
compared with infants born to mothers with normal weight. A
Journal of Paediatrics and Child Health (2018)
© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
Effect of BMI and GWG on infant growth
higher risk of overweight/obesity at age 12 months was also
found among the infants born to mothers with excessive GWG
(RR = 1.47, 95% CI: 1.18–1.63, P < 0.01) compared with infants
born to mothers with adequate GWG. The risk of childhood over-
weight/obesity according to 12 groups of maternal pre-pregnancy
BMI and GWG was also analysed. Compared with the offspring
of mothers with both pre-pregnancy normal weight and ade-
quate GWG, the risk of childhood overweight/obesity in infants
born to mothers with excessive GWG and all pre-pregnancy BMI
categories except for underweight were significantly higher
(all P < 0.01).
Then, the effects of GWG rates in early the and late periods on
childhood overweight or obesity were further investigated
(Fig. 2). There is a positive linear relationship between the first
trimester GWG rate and the probability of overweight/obesity
at 12 months of age. After adjusting for all cofounders, each
200 g/week increase in the first trimester GWG was associated
with a higher risk of childhood overweight or obesity at
12 months (RR = 1.31, 95% CI: 1.12–1.47, P < 0.01). Rates of
second and third trimester GWG showed no association with the
probability of overweight/obesity at 12 months.
Discussion
The increasing prevalence of childhood overweight and obe-
sity has been reported to be a global public health crisis in
almost all reports. In China, rapid economic development
and associated dramatic life-style changes have led to a sub-
stantial increase in the prevalence of obesity and related non-
communicable diseases.16 According to the Chinese National
Surveys on Students Constitution Health, the overweight
prevalence of children aged 7–18 years nearly doubled, from
4.1 in 2000 to 8.1% in 2010.17 Meanwhile, the Shanghai
Center for Disease Control indicated that the obesity preva-
lence of children was 3.76 in 1991 and increased to 13.53%
in 2009.18
Because of growing concern of the obesity epidemic, risk fac-
tors of childhood obesity have been widely investigated. Given
that both maternal pre-pregnancy BMI and GWG have been
associated with early childhood growth that predisposes children
to overweight or even obesity, evaluating their interaction is of
great importance for both understanding the complex determi-
nants of and developing effective interventions for childhood
overweight and obesity. The present study indicated that both
higher maternal pre-pregnancy BMI and excessive GWG were
associated with higher Z-scores for weight for length during the
first year of life. Excessive GWG, especially the first-trimester
GWG, strengthened the effects of maternal pre-pregnancy BMI
on early life offspring growth and development.
In 2009, the IOM set new guidelines for GWG based on pre-
pregnancy BMI. This recommendation, varying by pre-pregnancy
BMI, was based on the WHO categories, which were described
as: <18.5 kg/m2 (underweight), 18.5–24.9 kg/m2 (normal),
25–29.9 kg/m2 (overweight) and ≥30 kg/m2 (obese). However,
the categories of adult BMI are different in China: <18.5 kg/m2
(underweight), 18.5–24 kg/m2 (normal), 24–28 kg/m2 (over-
weight) and ≥28 kg/m2 (obese). Obviously, the Chinese adult
BMI classification standards are lower than the WHO BMI cate-
gories for normal, overweight and obese. There were no official
5
Effect of BMI and GWG on infant growth
GWG recommendations in China. Although several studies have
attempted to provide Chinese GWG recommendations,19 none of
them have been widely accepted. Most Chinese studies defined
the adequacy of GWG according to the Chinese maternal pre-
pregnancy BMI classification standard and the 2009 IOM GWG
recommendations, and the relationships of GWG based on the
revised criteria and birth outcomes have been reported.19,20 How-
ever, a rare study reported the association of GWG with Chinese
infant growth. This study demonstrated that excessive maternal
pre-pregnancy BMI (overweight and obesity) and GWG, which
were based on Chinese maternal pre-pregnancy BMI cut-off
values, independently increased the risk of infant adiposity, con-
firming the importance of these two factors in shaping offspring
growth for Chinese population.
The joint associations of maternal pre-pregnancy BMI and GWG
with the risk of infant overweight or obesity were also explored. The
present study showed that, compared with infants born to mothers
with pre-pregnancy normal weight and adequate GWG, infants born
to mothers with pre-pregnancy normal weight or overweight/obesity
and also with excessive GWG had a higher risk of childhood over-
weight/obesity at 12 months of age. Our results were consistent with
studies conducted by Heerman et al.21 indicating that excessive GWG
amplified the effect of pre-pregnancy overweight or obesity on infant
growth. It is suggested that maternal over-nutrition during pregnancy
may lead to fetal over-nutrition that would cause increased fetal fat
deposition.22 Moreover, mothers with excessive GWG may have a
high energy diet and low levels of physical activity during their preg-
nancy, and they may pass them on to their offspring,23 thereby lead-
ing to the risk of adiposity in later life.
We further explored which trimester greatly influenced the off-
spring growth. It is found that the first trimester GWG rate was
incrementally associated with the risk of offspring overweight/obe-
sity in early childhood. Excessive early pregnancy GWG represents
greater maternal fat deposition and possibly a state of maternal
dysmetabolism.24 This altered maternal environment may interact
with placental factors, leading to the increased supply of fuels to
the fetus.25 Epidemiological evidence from the Avon Longitudinal
Study of Parents and Children cohort shows that greater GWG in
early pregnancy is related to higher DNA methylation in offspring
cord blood, suggesting a possible epigenetic mechanism for the
adverse health outcomes of early GWG.26
A Cochrane review published in 2017 has investigated the
effectiveness of diet or exercise, or both, interventions for pre-
venting excessive weight gain during pregnancy.27 A total of
49 randomly clinical trials (RCTs) involving 11 444 women were
included. The diets tested were low sugar (low glycaemic load),
diabetic, low-calorie or low-fat diets, with or without food diaries
and regular weighing. The exercise interventions were most often
of moderate intensity and involving regular walking, dance or
aerobic classes. Overall, weight management interventions led to
a reduction in the number of women gaining excess weight by a
fifth (20%; range 13–27%) over the pregnancy. Most included
studies were performed in developed countries, and it is neces-
sary to conduct a large RCT to evaluate whether these interven-
tions are applicable to lower-income settings.
A limitation of the present study was the influence of residual
confounding from other unique environmental factors. As a ret-
rospective cohort study, although we have tried to adjust for
potential confounding factors, several factors such as family
6 Journal of Paediatrics and Child Health (2018)
© 2018 Paediatrics and Child Health Division (The Royal Australasian College of Physicians)
W Zhang et al.
socio-economics were not collected. Moreover, this study used
objective measurements for height and weight in the EMR within
365 days prior to the estimated date of conception. The anthro-
pometric measurements were taken as a part of routine care and
not specifically for the purposes of this study. Although it may
cause information bias, our calculated BMI based on EMR data
represents an improvement over previous studies that used self-
reported pre-pregnancy BMI measures.28,29 In addition, because
the infant growths were only followed up for 12 months, the
effects of maternal pre-pregnancy BMI and GWG on offspring’s
growth in the late years were not assessed. We are prospectively
collecting the offspring’s development information, and the asso-
ciations with those two risk factors with children’s later growth
may be reported in the future.
Conclusion
The present study indicated that the interaction between mater-
nal pre-pregnancy BMI and GWG shapes infant growth in the
first year of life. Maternal excessive GWG, regardless of pre-
pregnancy BMI, was associated with an increased risk of offspring
overweight or obesity at 12 months of age, and the first-trimester
GWG contributed significantly to the childhood obesity outcomes.
These findings highlight the importance of the preconception and
prenatal periods for paediatric obesity prevention.
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