Received: 24 May 2019 Revised: 18 September 2019 Accepted: 28 September 2019

DOI: 10.1111/ijpo.12589

ORIGINAL RESEARCH

Total and trimester‐specific gestational weight gain and infant

anthropometric outcomes at birth and 6 months in low‐income
Hispanic families

Andrea L. Deierlein PhD, MPH1 | Mary Jo Messito MD2 | Michelle Katzow MD, MS2 |

Lauren Thomas Berube MS, RDN3 | Cara D. Dolin MD, MPH4 | Rachel S. Gross MD, MS2

1
Department of Epidemiology, New York
University College of Global Public Health, Abstract
New York, USA
Objective: To describe total and trimester‐specific gestational weight gain (GWG)
2
Division of General Pediatrics, Department of
among low‐income Hispanic women and determine whether these GWG exposures
Pediatrics, New York University School of
Medicine, New York, USA are associated with infant anthropometric outcomes at birth and 6 months.
3
Department of Nutrition and Food Studies,
Study Design: Data were from 448 mother‐infant pairs enrolled in the Starting
New York University Steinhardt, New York,
USA Early child obesity prevention trial. Prenatal weights were used to calculate total
4
Department of Obstetrics and Gynecology, GWG and 2nd and 3rd trimester GWG rates (kg/week) and categorized as inadequate,
University of Pennsylvania Perelman School of
Medicine Philadelphia, Pennsylvania
adequate, and excessive according to the 2009 Institute of Medicine recommenda-
tions. Multivariable linear and modified Poisson regressions estimated associations
Correspondence
Andrea L. Deierlein, 715/719 Broadway Room
of infant anthropometric outcomes (birthweight, small‐for‐gestational age [SGA],
1218, New York, NY 10003.. large‐for‐gestational age [LGA], rapid weight gain, and weight‐for‐age, length‐for‐
Email: ald8@nyu.edu
age, and weight‐for‐length z‐scores at 6 months) with GWG categories.
Funding information Results: For total GWG, 39% and 27% of women had inadequate and excessive
Eunice Kennedy Shriver National Institute of
Child Health and Human Development, Grant/ GWG, respectively. 57% and 46% had excessive GWG rates in the 2nd and 3rd trimes-
Award Number: K23HD081077; National ters, respectively, with 29% having excessive rates in both trimesters. Inadequate
Institute of Food and Agriculture, Grant/Award
Number: 2011‐68001‐30207 total GWG was associated with lower infant weight and length outcomes (ß range
for z‐scores = −0.21 to −0.46, p < 0.05) and lower risk of LGA (adjusted Relative Risk,
aRR = 0.38; 95% confidence intervals, CI: 0.16, 0.95) and rapid weight gain
(aRR = 0.72; 95%CI: 0.51, 1.00). GWG rates above recommendations in the 2nd tri-
mester or 2nd/3rd trimesters were associated with greater weight outcomes at birth
and 6 months (ß range for z‐scores = 0.24 to 0.35, p < 0.05).
Conclusions: Counseling women about health behaviors and closely monitoring
GWG beginning in early pregnancy is necessary, particularly among populations at
high‐risk of obesity.

K E Y W OR D S

anthropometry, Hispanic Americans, infant, pediatric obesity, pregnancy, weight gain

Abbreviations and Acronyms: GWG, Gestational Weight Gain; BMI, Body Mass Index; SGA, Small‐for‐Gestational Age; LGA, Large‐for‐Gestational Age; IOM, Institute of Medicine; aRR, Adjusted
Relative Risk; CI, Confidence Interval; SD, Standard Deviation

Pediatric Obesity. 2019;1–9. wileyonlinelibrary.com/journal/ijpo © 2019 World Obesity Federation 1

2 DEIERLEIN
1 | I N T RO D U CT I O N
Inappropriate gestational weight gain (GWG), defined as below or
above the 2009 Institute of Medicine's (IOM) recommendations, is
associated with infant growth, independent of maternal pre‐
1,2
pregnancy body mass index (BMI). In a recent systematic review
and meta‐analysis of more than one million pregnant women, inade-
quate GWG (below the recommendations) was associated with
increased risk of preterm birth and infants with small‐for‐gestational
age (SGA), while excessive GWG (above the recommendations) was
associated with greater risk of infants with large‐for‐gestational age
1 missing information on GWG (n = 26 missing weight measurements
(LGA) and macrosomia. These relationships are significant given that
both SGA and LGA are risk factors for the development of obesity
and associated co‐morbidities, such as diabetes and cardiovascular dis-
ease, later in life.3 Other studies link GWG with offspring growth and
adiposity extending beyond birth, from infancy and childhood through
early adulthood.4
It is likely that trimester‐specific rates of GWG are independently
and differentially associated with fetal growth outcomes5-14 and adi-
posity in later childhood.15-18 Evidence varies regarding which trimes-
ter or pattern of GWG is most influential. GWG during mid‐ to later
pregnancy, particularly the 2nd trimester, has often been directly asso-
6,7,10,12,13
ciated with offspring anthropometric outcomes.
st
GWG during the 1 trimester has been positively associated with off-
spring weight or adiposity in some9,16 but not all7,13 studies, and other
studies suggest significant roles for GWG in all three trimesters.
A main limitation of these previous findings is that they were based on
mostly white populations.
Hispanics are the largest minority group in the United States and
Hispanic women and children are at‐high risk for experiencing obe-
sity, 19,20
yet this population remains under‐represented in most studies.
To fill these gaps, we sought to describe total GWG and 2nd and 3rd
trimester‐specific GWG rates among an urban, low‐income, Hispanic
prenatal cohort and to determine whether these GWG exposures were
associated with infant anthropometric outcomes at birth and 6 months.
2 | METHODS
Data were from pregnant, low‐income Hispanic women enrolled in the
Starting Early child obesity prevention trial, a randomized controlled
trial of a primary care‐based early childhood obesity prevention pro-
gram, which was initiated in women during late pregnancy and contin-
ued until child age 3 years old.21 Bellevue Hospital Center, the New
York City Health and Hospitals Corporation, and the institutional
review boards of New York University School of Medicine approved
this study. The study was registered on clinicaltrials.gov
(NCT01541761).
2.1 | Study participants
Researchers enrolled pregnant women at 28–32 weeks' gestation
from prenatal clinics affiliated with a large urban medical center in
ET AL.
New York City. Inclusion criteria were: at least 18 years of age; self‐
reported Hispanic/Latina ethnicity only; fluent in English or Spanish;
singleton pregnancy; access to a phone; no history of severe
medical/psychiatric illness or drug/alcohol abuse; and planned to con-
tinue prenatal and pediatric care at the study sites. Women with
severe medical/psychiatric illness or fetal anomalies that could affect
infant feeding or growth were not eligible. Trained, bilingual research
staff obtained written informed consent from women and conducted
baseline assessments in English or Spanish. A total of 533 women
were randomized in the study, of which 518 had live births and infor-
mation on birthweight and gestational age. There were 70 women
in the 2nd and 3rd trimesters and n = 44 missing weight measurement
in the 2nd trimester), resulting in a final analytic sample of 448 mother‐
infant pairs. There were 381 (85%) mother‐infant pairs with complete
information on infant weight and length measurements at 6 months
old.
2.2 | Infant anthropometric outcomes
Infant gestational age and all anthropometric measurements were
taken from electronic medical records of the birth hospitalization
Higher
and well‐child visits at approximately 6 months of age (mean (standard
deviation, SD) = 6.2 (0.5) months). The World Health Organization
14,17,18 growth reference was used to calculate sex‐specific: birthweight z‐
score, and infant weight‐for‐age, length‐for‐age, and weight‐for‐
length z‐scores at 6 months.22 Small‐for‐gestational age (SGA) was
defined as birthweight‐for‐gestational age < 10th percentile and
large‐for‐gestational age (LGA) was defined as birthweight‐for‐
gestational age > 90th percentile.23 Rapid infant weight gain between
birth and 6 months was defined as >0.67 change in z‐scores (standard
deviation units) in weight‐for‐age between birth and 6 months.24
2.3 | Maternal pre‐pregnancy body mass index and
gestational weight gain
Maternal height and weights measured at clinic visits throughout
pregnancy and at delivery (median = 9 visits, range = 3–13) were
obtained from electronic medical records. Pre‐pregnancy weight was
defined as the first measured weight at ≤12 weeks' gestation (mean
(SD) = 7.8 (1.3) weeks, n = 365, 81%) or self‐reported pre‐pregnancy
weight (if first measured weight > 12 weeks' gestation; n = 83, 19%).
To examine the use of the self‐reported pre‐pregnancy weights
among women missing first measured weights, we compared the first
measured weight and self‐reported pre‐pregnancy weight among
women with both weights (n = 365). The correlation coefficient
between the two weights was very high (r = 0.98). Pre‐pregnancy
BMI (kg/m2) was calculated using pre‐pregnancy weight and height.
Pre‐pregnancy BMI was categorized as underweight (<18.5 kg/m2),
normal weight (18.5‐ <25.0 kg/m2), overweight (25.0‐ < 30.0 kg/m2),
and obese (≥30.0 kg/m2).2
DEIERLEIN ET AL. 3

Total GWG (kg) was calculated as the difference between the
recorded weight at delivery and the pre‐pregnancy weight.
Trimester‐specific rates of GWG for the 2nd and 3rd trimesters were
nd
also determined. GWG during the 2 trimester (kg) was calculated
as the difference between the last 2nd trimester weight measurement
(at 24–29 weeks' gestation, mean (SD) = 27.3 (1.3) weeks) and the last
1st trimester weight measurement (at 11–19 weeks' gestation, mean
rd
(SD) = 13.5 (1.9) weeks). GWG during the 3 trimester was calculated
as the difference between weight at delivery (all women had a weight
measurement at delivery, mean (SD) = 39.4 (1.3) weeks) and the last
2nd trimester weight measurement. Rates of GWG during the 2nd
rd
and 3 trimesters (kg/week) were then calculated by dividing the
amount of weight gained between the two measurements (e.g., the
amount of weight gained from the last 1st trimester visit to the last
2nd trimester visit) by the respective number of gestational weeks
between the two weight measurements. The mean (SD) number of
weeks between weight measurements was 13.8 (2.3) weeks for 2nd
trimester GWG rate and 12.1 (1.8) weeks for 3rd trimester GWG rate.
The 2009 IOM GWG recommendations2 provide ranges for total
nd rd
GWG and GWG rates in the 2 and 3 trimesters, specific to a
women's pre‐pregnancy BMI status (Table 1). All GWG variables were
categorized as inadequate, adequate, or excessive, if they were below,
within, or above, the IOM recommended ranges, respectively. Since
total GWG was calculated using pre‐pregnancy weight, we compared
the use of self‐reported versus first measured weight (we also com-
pared mean gestational age at first measured weight) across categories
of total GWG. No differences were observed (p > 0.05). Lastly, we
examined patterns of meeting IOM recommendations by combina-
tions of 2nd and 3rd trimester‐specific GWG: inadequate/adequate
(≤ adequate) GWG during both the 2nd and 3rd trimesters (reference);
≤ adequate GWG during the 2nd trimester and excessive GWG during
the 3rd trimester; excessive GWG during the 2nd trimester and ≤ ade-
quate GWG during the 3rd trimester; and excessive GWG during both
the 2nd and 3rd trimesters.
2.4 | Covariates
Information on maternal age (years), marital status (single or
married/living with partner), nulliparity (yes or no), employment status
(employed or not employed), pre‐pregnancy diabetes diagnosis (yes or
no), and level of education (did not graduate high school or high school
graduate) were collected at the baseline assessment. Women reported
on their country of birth (United States, Mexico, Ecuador, or other

TABLE 1 Institute of Medicine (IOM) 2009 gestational weight gain (GWG) recommendations and distributions of total and 2nd and 3rd trimester‐
specific rates of GWG, stratified by prepregnancy BMI status, among women participating in the starting early child obesity prevention trial
(n = 448)

Total Underweight Normal weight Overweight Obese

n = 448 n=7 n = 148 n = 152 n = 141

IOM recommended range (kg) 12.5–18 11.5–16 7–11.5 5–9

Total GWG, mean (SD) 9.7 (5.3) 12.5 (3.0) 10.8 (4.7) 10.3 (5.2) 7.9 (5.5)
Inadequate, n (%) 173 (39) 4 (57) 88 (59) 39 (26) 42 (30)
Adequate, n (%) 156 (35) 3 (43) 42 (28) 60 (39) 51 (36)
Excessive, n (%) 119 (27) 0 (0) 18 (12) 53 (36) 48 (34)
IOM recommended range (kg/week) 0.45–0.59 0.36–0.45 0.23–0.32 0.18–0.27
2nd trimester, mean (SD) 0.40 (0.21) 0.47 (0.16) 0.48 (0.17) 0.42 (0.20) 0.30 (0.22)
Inadequate, n (%) 100 (22) 3 (43) 36 (24) 20 (13) 41 (29)
Adequate, n (%) 94 (21) 2 (29) 31 (21) 32 (21) 29 (21)
Excessive, n (%) 254 (57) 2 (29) 81 (55) 100 (66) 71 (50)
IOM recommended range (kg/week) 0.45–0.59 0.36–0.45 0.23–0.32 0.18–0.27
3rd trimester, mean (SD) 0.34 (0.24) 0.40 (0.19) 0.33 (0.27) 0.35 (0.21) 0.33 (0.25)
Inadequate, n (%) 157 (35) 3 (43) 78 (53) 36 (24) 40 (28)
Adequate, n (%) 86 (19) 3 (43) 28 (19) 30 (20) 25 (18)
Excessive, n (%) 205 (46) 1 (14) 42 (28) 86 (57) 76 (54)
Rates of GWG in 2 T and 3T*
2 T and 3 T ≤ adequate, n (%) 120 (27) 5 (71) 53 (36) 27 (18) 35 (25)
2 T ≤ adequate; 3 T excessive, n (%) 74 (17) 0 (0) 14 (9) 25 (16) 35 (25)
2 T excessive; 3 T ≤ adequate, n (%) 123 (27) 1 (14) 53 (36) 39 (26) 30 (21)
2 T and 3 T excessive, n (%) 131 (29) 1 (14) 28 (19) 61 (40) 41 (29)

2 T, 2nd Trimester; 3 T, 3rd Trimester; BMI, Body Mass Index

*Combinations of rates of GWG during 2 T and 3 T; ≤Adequate is defined as Inadequate or Adequate rate of GWG.
4 DEIERLEIN
Latin American countries, which included the Dominican Republic,
Puerto Rico, and Colombia), primary language spoken (Spanish or
English), and number of years living in the United States (≤5, >5–10,
>10–20, and > 20 years/born in the United States). None of the
women reported smoking cigarettes during pregnancy. Gestational
diabetes diagnosis (yes or no) was collected from the medical record.
2.5 | Statistical analysis
Statistical analyses were performed using STATA Version 15.0
(StataCorp LLC, College Station, TX). Descriptive statistics were used
to characterize total GWG and trimester‐specific GWG rates for the
population. Analysis of variance and t‐tests were used to examine
bivariate associations between GWG variables and selected maternal
and infant characteristics. Multivariable linear regression analyses
were used to estimate associations of categories (inadequate, ade-
quate, excessive) of total GWG and trimester‐specific rates of GWG
with continuous infant anthropometric outcomes (birthweight z‐
scores and weight‐for‐age, length‐for‐age, and weight‐for‐length z‐
scores at 6 months). Multivariable modified Poisson regression (with
robust error variance) analyses were used to estimate adjusted relative
risks (aRR) and 95% confidence intervals (CIs) for associations of cate-
gories of total GWG and trimester‐specific GWG with dichotomous
infant anthropometric outcomes (SGA, LGA, and rapid infant weight
gain). Final models were adjusted for continuous maternal age,
prepregnancy BMI, and nulliparity (yes/no). Models for birthweight,
weight‐for‐age, length‐for‐age, and weight‐for‐length z‐scores were
also adjusted for gestational age. Additional adjustment of models for
the remaining covariates did not appreciably change the observed
associations. We also conducted sensitivity analyses among the full
sample excluding women with underweight, pre‐pregnancy diabetes,
gestational diabetes, or infants with gestational age < 37 weeks
(n = 400 for birth outcomes and n = 340 for outcomes at 6 months).
The observed associations from these analyses did not differ in
strength or magnitude from those using the full sample; therefore, the
full sample was retained for all statistical analyses. Based on previous
studies, we assessed effect modification by pre‐pregnancy BMI status
(women with underweight/normal weight compared to women with
overweight/obesity).6,16,17 Interaction terms were tested in regression
models using Wald tests with a level of significance set at p < 0.05.
3 | RESULTS
Mean (SD) and IOM‐based categories of total and trimester‐specific
rates of GWG for the study population are shown in Table 1. Differ-
ences in patterns of GWG were observed by women's prepregnancy
BMI status. Among women with pre‐pregnancy BMI status in the nor-
mal weight range, the majority had inadequate total GWG (59%),
excessive 2nd trimester rate of GWG (55%), and inadequate 3rd trimes-
ter rate of GWG (53%). Over one‐third of women with overweight
and obesity had excessive total GWG (36% and 34%, respectively)
and the majority had excessive 2nd (6% and 51%, respectively) and
ET AL.
3rd trimester (58% and 52%, respectively) rates of GWG (Table 1).
Table 2 displays the distributions of selected maternal and infant char-
acteristics, as well as mean total and 2nd and 3rd trimester‐specific
rates of GWG. The majority of women were younger than 30 years,
married, parous, born outside of the United States, with
overweight/obesity, and had a high school education or less. Lower
total GWG and trimester‐specific rates of GWG were observed among
women who were older (>30 years) or had higher pre‐pregnancy BMI
(≤ 25.0 kg/m2) (p < 0.05). Greater total GWG but lower 2nd trimester
rate of GWG was observed among women who were parous com-
pared to those who were nulliparous (p < 0.05, Table 2).
Mean (SD) z‐scores were 0.17 (0.97) for birthweight and 0.43
(0.99), 0.35 (1.19), and 0.41 (1.03) for weight‐for‐age, length‐for‐age,
and weight‐for‐length, respectively, at 6 months. Results from multi-
variable linear and logistic regression revealed several associations
between GWG and infant anthropometric outcomes (Table 3). Com-
pared to infants of women with adequate total GWG, infants of those
with inadequate GWG had lower mean birthweight z‐scores
(ß = −0.21; 95% CI: −0.39, −0.04) and weight‐for‐age (ß = −0.44;
95% CI: −0.66, −0.21), length‐for‐age (ß = −0.46; 95% CI: −0.73,
−0.19), and weight‐for‐length (ß = −0.25; 95% CI: −0.49, −0.002) z‐
scores at 6 months. They were also less likely to be LGA (aRR = 0.38;
95%CI: 0.16, 0.95) or have rapid infant weight gain (aRR = 0.72; 95%
CI: 0.51, 1.00). Inadequate 2nd trimester rate of GWG was associated
with lower weight‐for‐age z‐scores at 6 months (ß = −0.33; 95% CI:
−0.63, −0.03). Excessive total GWG and 2nd and 3rd trimester‐specific
rates of GWG were not associated with any of the selected infant
outcomes.
Patterns of 2nd and 3rd trimester‐specific GWG rates were differ-
entially associated with infant anthropometric outcomes (Table 4).
Compared to infants of women with ≤ adequate 2nd and 3rd trimester
GWG rates, those of women with excessive 2nd trimester and ≤ ade-
quate 3rd trimester GWG rates had greater mean birthweight z‐scores
(ß = 0.24; 95% CI: 0.04, 0.45) and weight‐for‐age (ß = 0.27; 95% CI:
−0.001, 0.53) and weight‐for‐length (ß = 0.35; 95% CI: 0.07, 0.64) z‐
scores at 6 months. Similar associations were observed for infants of
mothers with excessive 2nd and 3rd trimester GWG rates. Infant
anthropometric outcomes were not associated with ≤ adequate 2nd
trimester GWG rates and excessive 3rd trimester GWG rates. Effect
modification by pre‐pregnancy BMI status was not observed.
4 | DISCUSSION
In this urban population of low‐income, Hispanic pregnant women, the
majority of women with pre‐pregnancy weight in the healthy range
had inadequate or adequate total GWG but more than half had exces-
sive 2nd trimester GWG rates. Among women with pre‐pregnancy
overweight and obesity, approximately one third had excessive total
GWG and the majority had excessive GWG rates during both the
2nd and 3rd trimesters. Inadequate total GWG was associated with
lower birthweight z‐scores and risk of LGA, as well as lower weight‐
for‐age, length‐for‐age, and weight‐for‐length z‐scores at 6 months,
DEIERLEIN ET AL. 5

TABLE 2 Distributions of selected characteristics and mean total and 2nd and 3rd trimester‐specific rates of gestational weight gain (GWG)
among women participating in the starting early child obesity prevention trial (n = 448)

Characteristic n (%) Total GWG (kg) 2nd trimester (kg/week) 3rd trimester (kg/week)

Maternal age (years), mean (SD) 28.4 (6.0)

18–25 154 (34) 10.2 (5.6) 0.46 (0.21)* 0.36 (0.28)
25‐ < 30 122 (27) 10.1 (5.3) 0.38 (0.21) 0.36 (0.23)
30‐ < 35 96 (21) 9.2 (5.2) 0.37 (0.22) 0.30 (0.21)
> = 35 76 (17) 8.9 (4.5) 0.34 (0.18) 0.32 (0.22)
Pre‐pregnancy BMI, mean (SD) 27.7 (5.5)
Underweight 7 (2) 12.5 (3.0)* 0.47 (0.16)* 0.40 (0.19)
Normal weight 148 (33) 10.8 (4.7) 0.48 (0.17) 0.33 (0.27)
Overweight 152 (34) 10.3 (5.2) 0.42 (0.20) 0.35 (0.21)
Obese 141 (31) 7.9 (5.5) 0.30 (0.22) 0.33 (0.25)
Marital status 448
Not married 120 (27) 10.3 (6.0) 0.43 (0.23) 0.34 (0.28)
Married 328 (73) 9.5 (4.9) 0.39 (0.21) 0.34 (0.23)
Education 448
Less than high school 151 (34) 9.4 (5.2) 0.37 (0.20) 0.35 (0.24)
High school grad 270 (60) 9.8 (5.2) 0.41 (0.21) 0.33 (0.24)
College graduate 27 (6) 10.3 (6.4) 0.45 (0.25) 0.34 (0.30)
Nulliparous 448
No 287 (64) 9.1 (5.0)* 0.36 (0.20)* 0.33 (0.21)
Yes 161 (36) 10.9 (5.5) 0.47 (0.21) 0.36 (0.29)
Birth country 448
United States 81 (18) 10.1 (6.4) 0.42 (0.25) 0.36 (0.24)
Mexico 222 (50) 9.2 (4.8) 0.38 (0.19) 0.32 (0.23)
Ecuador 76 (17) 9.8 (4.5) 0.41 (0.19) 0.35 (0.19)
Other Latin American countries 69 (15) 11.0 (6.0) 0.43 (0.25) 0.39 (0.32)
Years in United States 441
<=5 years 92 (21) 10.6 (4.8) 0.43 (0.20) 0.38 (0.22)
>5–10 years 119 (27) 9.6 (5.3) 0.41 (0.20) 0.33 (0.24)
>10–20 years 135 (30) 9.0 (5.0) 0.37 (0.20) 0.31 (0.26)
>20 years or U.S. born 102 (23) 10.0 (5.9) 0.41 (0.24) 0.36 (0.24)
Primary language
English 84 (19) 10.2 (5.8) 0.42 (0.23) 0.36 (0.25)
Spanish 361 (81) 9.6 (5.1) 0.40 (0.21) 0.34 (0.24)
Pre‐pregnancy diabetes 447
No 434 (97) 9.8 (5.3) 0.41 (0.21)* 0.34 (0.24)
Yes 13 (3) 8.2 (5.2) 0.22 (0.18) 0.32 (0.24)
Gestational diabetes 448
No 430 (96) 9.8 (5.2) 0.40 (0.21) 0.34 (0.24)
Yes 18 (4) 7.9 (7.1) 0.37 (0.22) 0.23 (0.29)
Mode of delivery 448
Vaginal 356 (79) 9.7 (5.3) 0.40 (0.22) 0.34 (0.25)
Cesarean section 92 (21) 9.8 (5.1) 0.38 (0.19) 0.34 (0.23)
Infant sex 448

(Continues)
6 DEIERLEIN ET AL.

TABLE 2 (Continued)

Characteristic n (%) Total GWG (kg) 2nd trimester (kg/week) 3rd trimester (kg/week)
Male 222 (50) 9.9 (5.5) 0.40 (0.21) 0.35 (0.23)
Female 226 (50) 9.5 (5.1) 0.40 (0.21) 0.33 (0.26)
Gestational age, mean (SD) 39.4 (1.3)
> = 37 weeks 435 (97) 9.7 (5.3) 0.40 (0.21) 0.34 (0.24)
<37 weeks 13 (3) 9.3 (5.5) 0.39 (0.17) 0.34 (0.42)
Size at birth
SGA, <10th percentile 28 (6) 10.0 (5.0) 0.40 (0.19) 0.38 (0.23)
AGA, 10‐90th percentile 382 (85) 9.6 (5.2) 0.40 (0.21) 0.34 (0.25)
LGA, >90th percentile 38 (8) 10.8 (5.9) 0.40 (0.24) 0.35 (0.22)
Rapid weight gain 383
No 259 (68) 9.7 (5.1) 0.38 (0.21)* 0.35 (0.23)
Yes 122 (32) 9.6 (5.0) 0.43 (0.19) 0.32 (0.27)

SGA, Small‐for‐gestational age; AGA, appropriate‐for‐gestational age; LGA, large‐for gestational age; Rapid weight gain defined as >0.67 changed in weight‐
for‐age z‐scores between birth and 6 months.
*P value from analysis of variance or t‐tests, <=0.05.

TABLE 3 Multivariable* linear regression and multinomial modified Poisson regression estimating associations of infant anthropometric out-
comes with inadequate and excessive total gestational weight gain (GWG) and 2nd and 3rd trimester‐specific rates of GWG based on the 2009
Institute of Medicine recommendations among women participating in the starting early child obesity prevention trial

Total GWG 2nd trimester GWG rate 3rd trimester GWG rate

Inadequate Excessive Inadequate Excessive Inadequate Excessive

Infant
outcome n B (95% CI) B (95% CI) B (95% CI) B (95% CI) B (95% CI) B (95% CI)

BWT z‐score 448 −0.21 (−0.39, −0.04)† 0.12 (−0.08, 0.31) −0.14 (−0.37, 0.09) 0.16 (−0.03, 0.35) 0.02 (−0.20, 0.24) 0.03
(−0.17, 0.24)
WAZ at 381 −0.44 (−0.66, −0.21)† −0.21 (−0.46, 0.04) −0.33 (−0.63, −0.03)† 0.06 (−0.19, 0.31) 0.04 (−0.25, 0.32) 0.15
6 months (−0.12, 0.43)
LAZ at 381 −0.46 (−0.73, −0.19)† −0.15 (−0.45, 0.15) −0.24 (−0.61, 0.12) −0.12 (−0.43, 0.18) −0.12 (−0.46, 0.21) 0.08
6 months (−0.24, 0.41)
WLZ at 381 −0.25 (−0.49, −0.002)† −0.17 (−0.44, 0.10) −0.23 (−0.55, 0.08) 0.18 (−0.08, 0.45) 0.13 (−0.17, 0.44) 0.15
6 months (−0.14, 0.44)
aRR (95% CI) aRR (95% CI) aRR (95% CI) aRR (95% CI) aRR (95% CI) aRR (95% CI)
SGA 28/448 0.96 (0.39, 2.36) 0.97 (0.38, 2.46) 0.81 (0.28, 2.32) 0.61 (0.27, 1.38) 0.88 (0.25, 3.05) 1.64 (0.55, 4.91)
†
LGA 38/448 0.38 (0.16, 0.95) 1.53 (0.80, 2.91) 0.51 (0.20, 1.31) 1.04 (0.48, 2.25) 0.93 (0.41, 2.11) 1.01 (0.47, 2.17)
Rapid weight 122/ 0.72 (0.51, 1.00)† 0.68 (0.46, 1.01) 0.65 (0.40, 1.08) 0.97 (0.68, 1.38) 0.95 (0.62, 1.46) 1.05 (0.69, 1.58)
gain 381

Reference in all models is adequate GWG

aRR, adjusted Relative Risks; CI, Confidence Interval; BWT, birthweight; WAZ, weight‐for‐age z‐score; LAZ, length‐for‐age z‐score; WLZ, weight‐for‐length
z‐score; SGA, small‐for‐gestational age; LGA, large‐for‐gestational age; Rapid weight gain defined as >0.67 changed in weight‐for‐age z‐scores between
birth and 6 months.
*Adjusted for maternal age, pre‐pregnancy BMI, and nulliparity. Models for BWT, WAZ, LAZ, WLZ, and rapid weight gain also adjusted for gestational age.
†
P < 0.05

and lower risk of rapid infant weight gain. When examining trimester‐
nd
specific GWG, those with GWG patterns that included excessive 2
trimester GWG had infants with greater birthweight z‐scores and
weight‐for‐age and weight‐for‐length z‐scores at 6 months compared
to women with 2nd and 3rd trimester GWG rates within or below
recommendations.
Hispanic women often have lower GWG and are more likely to
have inadequate GWG compared to white women, independent of
DEIERLEIN ET AL. 7

TABLE 4 Multivariable* linear regression and multinomial modified Poisson regression estimating associations of infant anthropometric out-
comes with patterns of 2nd and 3rd trimester rates of gestational weight gain (GWG) based on the 2009 Institute of Medicine recommendations
(≤adequate GWG versus excessive GWG) among women participating in the starting early child obesity prevention trial

2 T, ≤adequate; 2 T, excessive; 2 T, excessive;

3 T, excessive 3 T, ≤adequate 3 T, excessive
n B (95% CI) B (95% CI) B (95% CI)

BWT z‐score 448 0.001 (−0.24, 0.24) 0.24 (0.04, 0.45)† 0.22 (0.02, 0.42)†
WAZ at 6 months 381 0.17 (−0.15, 0.48) 0.27 (−0.001, 0.53) 0.31 (0.05, 0.57)†
LAZ at 6 months 381 0.20 (−0.18, 0.58) −0.003 (−0.32, 0.32) 0.14 (−0.17, 0.46)
WLZ at 6 months 381 0.08 (−0.26, 0.64) 0.35 (0.07, 0.64)† 0.32 (0.04, 0.59)†
aRR (95% CI) aRR (95% CI) aRR (95% CI)
SGA 28/448 1.62 (0.58, 4.57) 0.47 (0.15, 1.47) 1.14 (0.45, 2.87)
LGA 38/448 1.20 (0.42, 3.40) 1.59 (0.68, 3.70) 1.44 (0.61, 3.40)
Rapid weight gain 122/381 1.30 (0.78, 2.15) 1.30 (0.85, 1.97) 1.21 (0.80, 1.84)

2 T, 2nd Trimester; 3 T, 3rd Trimester; aRR, adjusted Relative Risk; CI, Confidence Interval; BWT, birthweight; WAZ, weight‐for‐age z‐score; LAZ, length‐
for‐age z‐score; WLZ, weight‐for‐length z‐score; LGA, large‐for‐gestational age; Rapid weight gain defined as >0.67 changed in weight‐for‐age z‐scores
between birth and 6 months; ≤Adequate is defined as Inadequate or Adequate GWG.
*Models adjusted for pre‐pregnancy BMI, maternal age, and nulliparity. Models for BWT, WAZ, LAZ, WLZ, and rapid weight gain also adjusted for gesta-
tional age. Reference is 2 T, ≤Adequate: 3 T, ≤Adequate.
†
P < 0.05.

prepregnancy BMI.25 In the current study, 39% of women had inade-
quate total GWG and 27% had excessive total GWG. These frequen-
cies are somewhat more extreme than those reported among other U.
S. Hispanic populations in Massachusetts, California, North Carolina,
and Texas, ranging from 19–33% for inadequate and 36–52% for
26-30
excessive total GWG. The underlying contributors to lower
GWG in our population, particularly among women with normal
weight, compared to others are not clear. Our population was low‐
income, which, historically, is a risk factor for inadequate GWG.31
The majority of women were parous, Mexican, and lived in the U.S.
for 5–20 years and all of these characteristics were related to lower
mean GWG. Additionally, our population resided in an urban environ-
ment, which may provide more opportunities for active transport (e.g.,
walking and public transportation), possibly contributing to lower
GWG.32 Further investigation among Hispanic populations is neces-
sary to elucidate ethnic, nativity, social, and economic‐related factors
and their relation to maternal and child health outcomes.25
Similar to pre‐pregnancy BMI, total GWG has an independent, lin-
ear relationship with fetal growth.33 Inadequate GWG is associated
with higher risk of infant outcomes related to decreased growth,
including SGA and low birth weight, and lower risk of infant outcomes
related to excess growth, including macrosomia and LGA. Conversely,
excessive GWG is associated with higher risk of infant outcomes
related to excess growth and lower risk of decreased growth.1,2,34 In
the current study, inadequate GWG was associated with lower infant
anthropometric measurements at birth that were maintained through
6 months; it was also associated with decreased risk of LGA but not
increased risk of SGA. We found no association between excessive
total GWG and the selected infant anthropometric outcomes. The
low prevalence of SGA, LGA, and excessive GWG (6%, 8%, and 27%,
respectively) in our study may at least partially explain discrepancies
with findings from previous studies. However, our findings suggest
that inadequate GWG was associated with lower infant weight and
length measurements that remained within a healthy range. Given that
Hispanic populations have high rates of overweight and obesity, and
that GWG has been positively associated with the development of
obesity in both women and children,4,35 GWG below recommenda-
tions in this population may be safe if closely monitored.
Though GWG throughout pregnancy contributes to fetal growth
and development, evidence suggests that timing of gains may differen-
tially influence these outcomes. Weight gain in early pregnancy is pri-
marily maternal fat gain and is associated with cord blood hormones
related to offspring glucose and insulin regulation (during the 1st trimes-
ter), while weight gain in later pregnancy is attributed to fetal, placental,
and maternal gains and is associated with cord blood hormones related
to offspring growth and adiposity (during the 2nd trimester).36 In gen-
eral, findings from studies examining trimester‐specific GWG rates sug-
gest that mid‐to‐late pregnancy GWG rates are more strongly
associated with infant anthropometric outcomes compared to early
and later pregnancy.6-8,13,16,17 Sridhar et al. found that both 2nd and
3rd trimester GWG rates above the IOM recommendations were asso-
ciated with LGA, while only inadequate 2nd trimester GWG rates were
associated with SGA.6 Similarly, Pugh et al., identified four distinct
GWG trajectories and observed that combined rates of GWG in the
2nd and 3rd trimesters, but not the 1st trimester, strongly influenced
infant size for gestational age.7 Women with low and high GWG trajec-
tories during the 2nd and 3rd trimesters were more likely to have SGA
and LGA infants, respectively, compared to women in the reference tra-
jectory. Widen et al., also identified patterns of GWG and observed that
high 2nd trimester GWG rates, but not 1st or 3rd trimester rates, were
associated with higher infant birth weight and length.13 However,
Josefson et al., found that infants of mothers with excessive GWG
8 DEIERLEIN
beginning in the 1st trimester and maintained throughout pregnancy
had 13% and 26% greater birth weight and adiposity (measured using
the Pea Pod Infant Body Composition System), respectively, than
those of mothers who had steady, moderate gains throughout preg-
nancy.9 In the current study, when examining patterns of 2nd and
3rd GWG rates (Table 4), we found that patterns that included exces-
sive 2nd trimester GWG rates were associated with greater infant
weight outcomes at birth and 6 months (compared to
inadequate/adequate GWG rates during both trimesters). Differences
in study populations and methodologies, including assessment of
GWG (e.g., trimester‐specific GWG or patterns/trajectories of
GWG) and infant outcomes (e.g., weight, length, or body composi-
tion), make it difficult to directly compare results across studies. Col-
lectively, they highlight the importance of counseling women about
nutrition, physical activity, and weight gain starting well before the
second trimester, at the first prenatal visit or preferably during pre-
conception. This remains an area that requires active improvement,
since health care provider advice is associated with women's GWG
and only approximately a quarter of women report receiving advice
that is consistent with the IOM recommendations.37
The main strengths of this study include the collection of multiple
measured maternal weights during pregnancy, as well as infant mea-
surements at birth and 6 months, among an urban, Hispanic prenatal
cohort. However, this study had several limitations. Our findings
may not be generalizable to other Hispanic populations. Our sample
was composed of low‐income women, the majority of whom were
Mexican or Ecuadorean, without medical complications/illnesses and
not at risk for low birthweight infants. Infant length and weight are
not measurements of body composition, so we do not know whether
the observed changes in infant size are reflective of fat or lean mass.
Maternal pre‐pregnancy weight was based on measured weight at
the first prenatal visit (<12 weeks' gestation), which precluded exami-
nation of GWG during the 1st trimester, but allowed for calculations of
GWG (total and 2nd and 3rd trimester) based solely on measured
weights. Though the magnitude of error in self‐reported pre‐
pregnancy weights (used in most of the previous studies) tends to be
small, there is still substantial misreporting, especially among women
of minority groups and those with high pre‐pregnancy BMI.38 Lastly,
only 27% of women had excessive GWG, which is substantially below
national averages, and one third of women were within normal weight
range. Therefore, our study was likely under‐powered to examine
associations for some outcomes, such as LGA and SGA, as well as
effect modification by pre‐pregnancy BMI status. Effect modification
by pre‐pregnancy BMI is commonly considered in studies of GWG
and infant weight outcomes. Generally, studies report that positive
associations between birth weight and GWG decrease with increasing
BMI39; greater likelihood of adverse infant weight outcomes are also
observed with inadequate GWG (e.g., SGA) among women with nor-
mal weight and excessive GWG (e.g., LGA) among women with obe-
6,40
sity, but findings vary with study populations and offspring
outcomes. Despite the null findings in the current study, pre‐
pregnancy BMI is an established, independent predictor of offspring
weight outcomes.41
ET AL.
5 | CO NC LUSIO NS
Among an urban, low‐income Hispanic cohort of mother‐infant pairs,
we found that inadequate total GWG was associated with lower infant
weight outcomes at birth and 6 months. No associations were
observed for excessive total GWG. Patterns of 2nd and 3rd trimester
GWG rates that included excessive 2nd trimester GWG rates were
associated with greater infant weight outcomes. These findings are
consistent with previous literature among diverse populations of
women supporting the influential role of GWG during mid‐pregnancy
on offspring anthropometric measurements and adiposity. Counseling
women about health behaviors and closely monitoring GWG begin-
ning in early pregnancy is necessary, particularly among populations
at high‐risk of obesity.
CONFLIC T OF INT E RE ST
The authors declare no conflicts of interest.
AUTHOR CONT R IBUT IONS
A.D. wrote the paper and conducted statistical analyses. M.M. and R.
G. designed and conducted the research study and reviewed and
edited the final paper. M.K., L.B., C.D. contributed to data collection
and management and reviewed and edited the final paper.
FUNDING SOURCES
This study was supported by the National Institute of Food and Agri-
culture, United States Department of Agriculture (2011–68001‐
30207 [to M.M.]); and the Eunice Kennedy Shriver National Institute
of Child Health and Human Development (K23HD081077 [to R.G.]).
ORCID
Andrea L. Deierlein https://orcid.org/0000-0002-2731-4080
RE FE RE NC ES
1. Goldstein RF, Abell SK, Ranasinha S, et al. Association of Gestational
Weight Gain with Maternal and Infant Outcomes: a systematic review
and meta‐analysis. JAMA. 2017;317(21):2207‐2225.
2. IOM (Institute of Medicine) and NRC (National Research Council).
Weight Gain During Pregnancy: Reexamining the Guidelines. Washing-
ton, DC: The National Academies Press; 2009.
3. Oken E, Gillman MW. Fetal origins of obesity. Obes Res. 2003;11
(4):496‐506.
4. Schack‐Nielsen L, Michaelsen KF, Gamborg M, Mortensen EL,
Sørensen TIA. Gestational weight gain in relation to offspring body
mass index and obesity from infancy through adulthood. Int J Obes
(Lond). 2009;34(1):67‐74.
5. Abrams B, Selvin S. Maternal weight gain pattern and birth weight.
Obstet Gynecol. 1995;86(2):163‐169.
6. Sridhar SB, Xu F, Hedderson MM. Trimester‐specific gestational
weight gain and infant size for gestational age. PLoS ONE. 2016;11(7):
e0159500.
7. Pugh SJ, Albert PS, Kim S, et al. Patterns of gestational weight gain and
birthweight outcomes in the Eunice Kennedy Shriver National Institute
of Child Health and Human Development Fetal Growth Studies–
DEIERLEIN ET AL.
Singletons: a prospective study. Am J Obstet Gynecol. 2017;217
(3):346):e1‐e11.
8. Ruchat S‐M, Allard C, Doyon M, et al. Timing of excessive weight gain
during pregnancy modulates newborn anthropometry. J Obstet
Gynaecol Can. 2016;38(2):108‐117.
9. Josefson JL, Simons H, Zeiss DM, Metzger BE. Excessive gestational
weight gain in the first trimester among women with normal glucose
tolerance and resulting neonatal adiposity. J Perinatol. 2016;36
(12):1034‐1038.
10. Strauss RS, Dietz WH. Low maternal weight gain in the second or third
trimester increases the risk for intrauterine growth retardation. J Nutr.
1999;129(5):988‐993.
11. Gaillard R, Durmuş B, Hofman A, Mackenbach JP, Steegers EA, Jaddoe
VW. Risk factors and outcomes of maternal obesity and excessive
weight gain during pregnancy. Obesity. 2013;21(5):1046‐1055.
12. Hickey CA, Cliver SP, McNeal SF, Hoffman HJ, Goldenberg RL. Prena-
tal weight gain patterns and birth weight among nonobese black and
white women. Obstet Gynecol. 1996;88(4, Part 1):490.
13. Widen EM, Factor‐Litvak PR, Gallagher D, et al. The pattern of gesta-
tional weight gain is associated with changes in maternal body
composition and neonatal size. Matern Child Health J. 2015;19
(10):2286‐2294.
14. Starling AB, Brinton JT, Glueck DH, et al. Associations of maternal BMI
and gestational weight gain with neonatal adiposity in the healthy start
study. Am J Clin Nutr. 2015;101(2):302‐309.
15. Andersen CSG M, Sørensen TI, Nohr EA. Weight gain in different
periods of pregnancy and offspring's body mass index at 7 years of
age. Int J Pediatr Obes. 2011;6(2–2):e179‐e186.
16. Hivert MF, Rifas‐Shiman SL, Gillman MW, Oken E. Greater early and
mid‐pregnancy gestational weight gains are associated with excess adi-
posity in mid‐childhood. Obesity. 2016;24(7):1546‐1553.
17. Margerison‐Zilko CE, Shrimali BP, Eskenazi B, Lahiff M, Lindquist AR,
Abrams BF. Trimester of maternal gestational weight gain and off-
spring body weight at birth and age five. Matern Child Health J.
2012;16(6):1215‐1223.
18. Fraser A, Tilling K, MacDonald‐Wallis C, et al. Association of Maternal
Weight Gain in pregnancy with offspring obesity and metabolic and
vascular traits in childhood. Circulation. 2010;121(23):2557‐2564.
19. Hales CM, Carroll MD, Fryar CD. Ogden CL. Prevalence of Obesity
Among Adults and Youth: United States. NCHS Data Brief. 2015‐
2016;2017(288):1‐8.
20. Singh GK, Bari JN. Marked Disparities in Pre‐pregnancy Obesity and
Overweight Prevalence among US Women by Race/Ethnicity,
Nativity/Immigrant Status, and Sociodemographic Characteristics,
2012–2014. J Obes. 2019. 2019(2419263)
21. Gross RS, Mendelsohn AL, Gross MB, Scheinmann R, Messito MJ. Ran-
domized Controlled Trial of a Primary Care‐Based Child Obesity
Prevention Intervention on Infant Feeding Practices. J Pediatr.
2016;174:171‐7.e2.
22. WHO (World Health Organization). WHO Anthro (version 3.2.2, Janu-
ary 2011) and macros 2011. http://www.who.int/childgrowth/
softward/en/. Accessed July 1, 2018
23. Fenton TR. A systematic review and meta‐analysis to revise the Fenton
growth chart for preterm infants. BMC Pediatr. 2013;13(1):59.
24. Ong KK. Size at birth, postnatal growth and risk of obesity. HormRes.
2006;65:65.
25. Headen IE, Davis EM, Mujahid MS, Abrams B. Racial‐ethnic differences
in pregnancy‐related weight. Adv Nutr. 2012;3(1):83‐94.
9
26. Harvey MW, Braun B, Ertel KA, Pekow PS, Markenson G, Chasan‐
Taber L. Prepregnancy body mass index, gestational weight gain, and
odds of cesarean delivery in Hispanic women. Obesity. 2018;26
(1):185‐192.
27. Walker LO, Hoke MM, Brown A. Risk factors for excessive or inade-
quate gestational weight gain among Hispanic women in a US‐
Mexico border state. J Obstet Gynecol Neonatal Nurs. 2009;38
(4):418‐429.
28. Siega‐Riz AM, Adair LS, Hobel CJ. Institute of Medicine maternal weight
gain recommendations and pregnancy outcome in a predominantly His-
panic population. Obstet Gynecol. 1994;84(4, Part 1):565‐573.
29. Sangi‐Haghpeykar H, Lam K, Raine SP. Gestational weight gain among
Hispanic women. Matern Child Health J. 2014;18(1):153‐160.
30. Berggren EK, Stuebe AM, Boggess KA. Excess maternal weight gain
and large for gestational age risk among women with gestational diabe-
tes. Am J Perinatol. 2015;32(03):251‐256.
31. Hickey CA. Sociocultural and behavioral influences on weight gain dur-
ing pregnancy. Am J Clin Nutr. 2000;71(5):1364S‐1370S.
32. Skreden M, Øverby NC, Sagedal LR, et al. Change in active transporta-
tion and weight gain in pregnancy. ISBNPA. 2016;13(1):10.
33. Viswanathan M, Siega‐Riz AM, Moos MK, et al. Outcomes of maternal
weight gain. Evid Rep Technol Assess. 2008;168:1‐223.
34. Han Z, Lutsiv O, Mulla S, et al. Low gestational weight gain and the risk
of preterm birth and low birthweight: a systematic review and meta‐
analyses. Acta Obstet Gynecol Scand. 2011;90(9):935‐954.
35. Rasmussen KM, Abrams B, Bodnar LM, Butte NF, Catalano PM, Siega‐
Riz AM. Recommendations for weight gain during pregnancy in the
context of the obesity epidemic. Obstet Gynecol. 2010;116
(5):1191‐1195.
36. Rifas‐Shiman SL, Fleisch A, Hivert MF, Mantzoros C, Gillman MW,
Oken E. First and second trimester gestational weight gains are most
strongly associated with cord blood levels of hormones at delivery
important for glycemic control and somatic growth. Metabolism.
2017;69:112‐119.
37. Deputy NP, Sharma AJ, Kim SY, Olson CK. Achieving appropriate ges-
tational weight gain: the role of healthcare provider advice. J Womens
Health. 2018;27(5):552‐560.
38. Headen I, Cohen A, Mujahid M, Abrams B. The accuracy of self‐
reported pregnancy‐related weight: a systematic review. Obes Rev.
2017;18(3):350‐369.
39. Frederick IO, Williams MA, Sales AE, Martin DP, Killien M. Pre‐preg-
nancy body mass index, gestational weight gain, and other maternal
characteristics in relation to infant birth weight. Matern Child Health
J. 2008;12(5):557‐567.
40. Li N, Liu E, Guo J, et al. Maternal prepregnancy body mass index and
gestational weight gain on pregnancy outcomes. PLoS ONE. 2013;8
(12):e82310.
41. Voerman E, Santos S, Inskip H, et al. Association of gestational weight
gain with adverse maternal and infant outcomes. JAMA. 2019;321
(17):1702‐1715.
How to cite this article: Deierlein AL, Messito MJ, Katzow M,
Berube LT, Dolin CD, Gross RS. Total and trimester‐specific
gestational weight gain and infant anthropometric outcomes
at birth and 6 months in low‐income Hispanic families. Pediat-
ric Obesity. 2019. https://doi.org/10.1111/ijpo.12589