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1.  Gestational diabetes and childhood obesity: what is the link? 
Purpose of review
To review recently published studies examining the role of prepregnancy obesity in the relationship between gestational diabetes mellitus and childhood obesity.
Recent findings
Seven epidemiologic studies published from January 2011 to February 2012 differentiate between preexisting diabetes mellitus and gestational diabetes mellitus, and six of them examine the role of maternal obesity. In studies that account for maternal obesity as a covariate, the association between gestational diabetes mellitus and childhood obesity is attenuated significantly after adjustment for prepregnancy BMI. In the one study that does not adjust for maternal obesity, maternal glucose level during pregnancy is associated with greater offspring adiposity, independent of the child’s diet and lifestyle.
Summary
This review shows a positive association between maternal gestational diabetes mellitus and offspring overweight and obesity that is attenuated significantly after adjustment for prepregnancy BMI. The relationship between maternal gestational diabetes mellitus and offspring overweight and obesity could reflect fetal programming, shared genes and/or shared environments, such as postnatal diet and physical activity. Maternal gestational hyperglycemia and subsequent fetal hyperinsulinemia may predispose offspring to increased adiposity, impaired glucose tolerance, hyperinsulinemia, and insulin resistance. Because maternal obesity is a more prevalent condition than gestational diabetes mellitus and strongly associated with offspring obesity, effective interventions addressing prepregnancy obesity need to be further explored as they may have a greater public health impact on childhood overweight and obesity than those targeting women with gestational diabetes mellitus.
doi:10.1097/GCO.0b013e328359f0f4
PMCID: PMC4392761  PMID: 23000698
childhood obesity; gestational diabetes mellitus; prepregnancy obesity
2.  Racial/Ethnic Differences in the Prevalence of Gestational Diabetes Mellitus and Maternal Overweight and Obesity, by Nativity, Florida, 2004–2007 
Obesity (Silver Spring, Md.)  2013;21(1):E33-E40.
Objective
We examined the risk of gestational diabetes mellitus (GDM) among foreign-born and U.S.-born mothers by race/ethnicity and BMI category.
Design and Method
We used 2004–2007 linked birth certificate and maternal hospital discharge data of live, singleton deliveries in Florida to compare GDM risk among foreign-born and U.S.-born mothers by race/ ethnicity and BMI category. We examined maternal BMI and controlled for maternal age, parity, and height.
Results
Overall, 22.4% of the women in our study were foreign born. The relative risk (RR) of GDM among women who were overweight or obese (BMI ≥ 25.0 kg m−2) was higher than among women with normal BMI (18.5–24.9 kg m−2) regardless of nativity, ranging from 1.3 (95% confidence interval (CI) = 1.0, 1.9) to 3.8 (95% CI = 2.1, 7.2). Foreign-born women also had a higher GDM risk than U.S.-born women, with RR ranging from 1.1 (95% CI = 1.1, 1.2) to 2.1 (95% CI = 1.4, 3.1). This finding was independent of BMI, age, parity, and height for all racial/ethnicity groups.
Conclusions
Although we found differences in age, parity, and height by nativity, these differences did not substantially reduce the increased risk of GDM among foreign-born mothers. Health practitioners should be aware of and have a better understanding of how race/ethnicity and nativity can affect women with a high risk of GDM. Although BMI is a major risk factor for GDM, it does not appear to be associated with race/ethnicity or nativity.
doi:10.1002/oby.20025
PMCID: PMC4392762  PMID: 23404915
3.  Are Gestational Diabetes Mellitus and Preconception Diabetes Mellitus Less Common in Non-Hispanic Black Women than in Non-Hispanic White Women? 
Maternal and child health journal  2014;18(3):698-706.
Based on their higher risk of type 2 diabetes, non-Hispanic blacks (NHBs) would be expected to have higher gestational diabetes mellitus (GDM) risk compared to non-Hispanic whites (NHWs). However, previous studies have reported lower GDM risk in NHBs versus NHWs. We examined whether GDM risk was lower in NHBs and NHWs, and whether this disparity differed by age group. The cohort consisted of 462,296 live singleton births linked by birth certificate and hospital discharge data from 2004 to 2007 in Florida. Using multivariable regression models, we examined GDM risk stratified by age and adjusted for body mass index (BMI) and other covariates. Overall, NHBs had a lower prevalence of GDM (2.5 vs. 3.1 %, p < 0.01) and a higher proportion of preconception DM births (0.5 vs. 0.3 %, p ≤ 0.01) than NHWs. Among women in their teens (risk ratio 0.56, p < 0.01) and 20–29 years of age (risk ratio 0.85, p < 0.01), GDM risk was lower in NHBs than NHWs. These patterns did not change with adjustment for BMI and other covariates. Among women 30–39 years (risk ratio 1.18, p < 0.01) and ≥40 years (risk ratio 1.22, p < 0.01), GDM risk was higher in NHBs than NHWs, but risk was higher in NHWs after adjustment for BMI. Associations between BMI and GDM risk did not vary by race/ethnicity or age group. NHBs have lower risk of GDM than NHWs at younger ages, regardless of BMI. NHBs had higher risk than NHWs at older ages, largely due to racial/ethnic disparities in overweight/obesity at older ages.
doi:10.1007/s10995-013-1295-9
PMCID: PMC3884046  PMID: 23793482
Race; Ethnicity; Birth certificates; Prenatal; Gestational diabetes; Diabetes mellitus; Type 2 diabetes mellitus
4.  Adherence to Breastfeeding Guidelines and Maternal Weight 6 Years After Delivery 
Pediatrics  2014;134(0 1):S42-S49.
OBJECTIVES
There is a dearth of information on the long-term maternal effects of breastfeeding. The objective of this study was to examine adherence to breastfeeding recommendations of exclusive breastfeeding for ≥4 months and continuation of breastfeeding for ≥1 year and maternal weight retention 6 years after delivery.
METHODS
Using data from the Infant Feeding Practices Study II (IFPS II), we categorized women by the degree to which they met breastfeeding recommendations. Mothers’ self-reported weight 6 years after delivery (IFPS Year 6 Follow-Up) was compared with self-reported prepregnancy weight from IFPS II. Using linear regression models, adjusting for covariates, we examined associations between breastfeeding recommendation adherence and weight retention.
RESULTS
Of the 726 women in our study, 17.9% never breastfed. Among those who initiated breastfeeding, 29.0% breastfed exclusively for ≥4 months, and 20.3% breastfed exclusively for ≥4 months and continued breastfeeding for ≥12 months. Prepregnancy BMI modified the association between breastfeeding recommendation adherence and weight retention. Adjusting for covariates, we found no association between breastfeeding recommendations adherence and weight retention among normal and overweight mothers. Among obese mothers, there was a significant linear trend (P = .03), suggesting that those who fully adhered to breastfeeding recommendations retained less weight (−8.0 kg) than obese women who never breastfed.
CONCLUSIONS
This study suggests that improving adherence to breastfeeding recommendations may help reduce long-term maternal weight retention among obese mothers. Larger studies, with diverse populations and similar longitudinal designs, are needed to explore this relationship.
doi:10.1542/peds.2014-0646H
PMCID: PMC4294466  PMID: 25183755
breastfeeding; benefits; maternal weight; human milk; exclusivity; duration
5.  Consumption of Added Sugars and Cardiometabolic Risk Indicators Among US Adolescents 
Circulation  2011;123(3):249-257.
Background
Increased carbohydrate and sugar consumption has been associated with dyslipidemia among adults. However, the effect of high consumption of added sugars (caloric sweeteners) on measures of cardiometabolic risk among US adolescents is unknown.
Methods and Results
This was a cross-sectional study of 2,252 US adolescents (13–18 y) in the National Health and Nutrition Examination Survey (NHANES) 1999–2004. Dietary data from one 24-hour recall were merged with added sugar content data from the USDA MyPyramid Equivalents Databases. Multivariate-adjusted means of cardiometabolic indicators were estimated by added sugar consumption level (<10%, 10– <15%, 15– <20%, 20– <25%, 25– <30%, and ≥30% total energy) and weighted to be representative of US adolescents. Mean consumption of added sugars was 21.4% of daily energy intake. Adjusted mean high-density lipoprotein cholesterol (HDL) levels were lower, 1.38 mmol/L (95% CI: 1.32, 1.43) among the lowest consumers to 1.28 mmol/L (95% confidence interval [CI]: 1.23, 1.33) among the highest (p-trend=0.007). Geometric mean triglyceride levels ranged from 0.79 mmol/L (95% CI: 0.72, 0.86) to 0.89 mmol/L (95% CI: 0.83, 0.96) (p-trend=0.03) with greater consumption of added sugars. Among those overweight/obese (≥85th percentile body-mass-index [BMI]), HOMA-IRs were positively associated with added sugars (p-linear trend<0.001), averaging 78% higher among the highest vs. the lowest consumers (p<0.001). No significant trends were seen with low-density lipoproteins, body-mass-index, or blood pressure.
Conclusion
In US adolescents, consumption of added sugars is positively associated with measures of cardiometabolic risk. Long-term studies are needed to determine if reduction in added sugars will improve these parameters and, thereby decrease future cardiovascular events.
doi:10.1161/CIRCULATIONAHA.110.972166
PMCID: PMC4167628  PMID: 21220734
Sugars; cardiovascular disease risk factors; lipids; triglycerides; diabetes mellitus
6.  Parental and Home Environmental Facilitators of Sugar-Sweetened Beverage Consumption among Overweight and Obese Latino Youth 
Academic pediatrics  2013;13(4):348-355.
Objective
To explore parental and home environmental facilitators of sugar-sweetened beverage (SSB) and water consumption among obese/overweight Latino youth.
Methods
Semi-structured interviews were conducted with 55 overweight/obese Latino youth aged 10-18 and 55 parents, recruited from school-based clinics and a school in one West-coast district. All youth consumed SSBs regularly and lived in a home where SSBs were available. We used qualitative methods to examine key themes around beliefs about SSBs and water, facilitators of SSB and water consumption, and barriers to reducing SSB consumption.
Results
A few parents and youth believed that sports drinks are healthy. Although nearly all felt that water is healthy, most parents and about half of youth thought that tap water is unsafe. About half of parent-child dyads had discordant beliefs regarding their perceptions of tap water. About half of parents believed that home-made culturally relevant drinks (e.g., aguas frescas), which typically contain sugar, fruit, and water, were healthy due to their “natural” ingredients. Participants cited home availability as a key factor in SSB consumption. About half of parents set no rules about SSB consumption at home. Among those with rules, most parent-child pairs differed on their beliefs about the content of the rules, and youth reported few consequences for breaking rules.
Conclusions
Obesity programs for Latino youth should address misconceptions around water, and discuss culturally relevant drinks and sports drinks as potential sources of weight gain. Healthcare providers can help parents set appropriate rules by educating about the risks of keeping SSBs at home.
doi:10.1016/j.acap.2013.02.009
PMCID: PMC3706467  PMID: 23680295
Hispanic Americans; obesity; beverages; adolescent
7.  Prevalence Estimates of Gestational Diabetes Mellitus in the United States, Pregnancy Risk Assessment Monitoring System (PRAMS), 2007–2010 
Introduction
The true prevalence of gestational diabetes mellitus (GDM) is unknown. The objective of this study was 1) to provide the most current GDM prevalence reported on the birth certificate and the Pregnancy Risk Assessment Monitoring System (PRAMS) questionnaire and 2) to compare GDM prevalence from PRAMS across 2007–2008 and 2009–2010.
Methods
We examined 2010 GDM prevalence reported on birth certificate or PRAMS questionnaire and concordance between the sources. We included 16 states that adopted the 2003 revised birth certificate. We also examined trends from 2007 through 2010 and included 21 states that participated in PRAMS for all 4 years. We combined GDM prevalence across 2-year intervals and conducted t tests to examine differences. Data were weighted to represent all women delivering live births in each state.
Results
GDM prevalence in 2010 was 4.6% as reported on the birth certificate, 8.7% as reported on the PRAMS questionnaire, and 9.2% as reported on either the birth certificate or questionnaire. The agreement between sources was 94.1% (percent positive agreement = 3.7%, percent negative agreement = 90.4%). There was no significant difference in GDM prevalence between 2007–2008 (8.1%) and 2009–2010 (8.5%, P = .15).
Conclusion
Our results indicate that GDM prevalence is as high as 9.2% and is more likely to be reported on the PRAMS questionnaire than the birth certificate. We found no statistical difference in GDM prevalence between the 2 phases. Further studies are needed to understand discrepancies in reporting GDM by data source.
doi:10.5888/pcd11.130415
PMCID: PMC4068111  PMID: 24945238
8.  Racial/Ethnic Differences in the Percentage of Gestational Diabetes Mellitus Cases Attributable to Overweight and Obesity, Florida, 2004-2007 
Introduction
Gestational diabetes mellitus (GDM) affects 3% to 7% of pregnant women in the United States, and Asian, black, American Indian, and Hispanic women are at increased risk. Florida, the fourth most populous US state, has a high level of racial/ethnic diversity, providing the opportunity to examine variations in the contribution of maternal body mass index (BMI) status to GDM risk. The objective of this study was to estimate the race/ethnicity-specific percentage of GDM attributable to overweight and obesity in Florida.
Methods
We analyzed linked birth certificate and maternal hospital discharge data for live, singleton deliveries in Florida from 2004 through 2007. We used logistic regression to assess the independent contributions of women's prepregnancy BMI status to their GDM risk, by race/ethnicity, while controlling for maternal age and parity. We then calculated the adjusted population-attributable fraction of GDM cases attributable to overweight and obesity.
Results
The estimated GDM prevalence was 4.7% overall and ranged from 4.0% among non-Hispanic black women to 9.9% among Asian/Pacific Islander women. The probability of GDM increased with increasing BMI for all racial/ethnic groups. The fraction of GDM cases attributable to overweight and obesity was 41.1% overall, 15.1% among Asians/Pacific Islanders, 39.1% among Hispanics, 41.2% among non-Hispanic whites, 50.4% among non-Hispanic blacks, and 52.8% among American Indians.
Conclusion
Although non-Hispanic black and American Indian women may benefit the most from prepregnancy reduction in obesity, interventions other than obesity prevention may be needed for women from other racial/ethnic groups.
PMCID: PMC3406742  PMID: 22515970
9.  Trends in Prevalence of Obesity and Overweight Among Children Enrolled in the New York State WIC Program, 2002–2007 
Public Health Reports  2010;125(2):218-224.
SYNOPSIS
Objective
We examined recent overweight and obesity trends in a multiethnic population of low-income preschool children.
Methods
We defined overweight as sex-specific body mass index (BMI)-for-age ≥85th and <95th percentile and obesity as sex-specific BMI-for-age ≥95th percentile, and calculated them using demographic data and randomly selected height and weight measurements that were recorded while 2- to <5-year-old children were enrolled in the New York State (NYS) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) during 2002–2007.
Results
Obesity prevalence peaked at 16.7% in 2003, declined from 2003 through 2005, and stabilized at 14.7% through 2007. Among both boys and girls, the downward trend in annual prevalence of obesity was evident only among Hispanic children (22.8% boys and 20.9% girls in 2002 vs. 19.3% boys and 17.5% girls in 2007) and non-Hispanic black children (15.6% boys and 14.2% girls in 2002 vs. 13.6% boys and 12.4% girls in 2007). In contrast, the annual prevalence estimate for overweight showed an increasing trend from 2002 through 2007.
Conclusions
These results showed a slight decline in prevalence of childhood obesity and a continuing rise in prevalence of childhood overweight among children enrolled in the NYS WIC program during 2002–2007. Future research should investigate the extent to which the slight decline in childhood obesity prevalence may be attributable to population-based and high-risk obesity prevention efforts in NYS.
PMCID: PMC2821849  PMID: 20297748
10.  Caloric Sweetener Consumption and Dyslipidemia Among US Adults 
Context
Dietary carbohydrates have been associated with dyslipidemia, a lipid profile known to increase cardiovascular disease risk. Added sugars (caloric sweeteners used as ingredients in processed or prepared foods) are an increasing and potentially modifiable component in the US diet. No known studies have examined the association between the consumption of added sugars and lipid measures.
Objective
To assess the association between consumption of added sugars and blood lipid levels in US adults.
Design, Setting, and Participants
Cross-sectional study among US adults (n=6113) from the National Health and Nutrition Examination Survey (NHANES) 1999–2006. Respondents were grouped by intake of added sugars using limits specified in dietary recommendations (<5% [reference group], 5%–<10%, 10%–<17.5%, 17.5%–<25%, and ≥25% of total calories). Linear regression was used to estimate adjusted mean lipid levels. Logistic regression was used to determine adjusted odds ratios of dyslipidemia. Interactions between added sugars and sex were evaluated.
Main Outcome Measures
Adjusted mean high-density lipoprotein cholesterol (HDL-C), geometric mean triglycerides, and mean low-density lipoprotein cholesterol (LDL-C) levels and adjusted odds ratios of dyslipidemia, including low HDL-C levels (<40 mg/dL for men; <50 mg/dL for women), high triglyceride levels (≥150 mg/dL), high LDL-C levels (≥130 mg/dL), or high ratio of triglycerides to HDL-C (>3.8). Results were weighted to be representative of the US population.
Results
A mean of 15.8% of consumed calories was from added sugars. Among participants consuming less than 5%, 5% to less than 17.5%, 17.5% to less than 25%, and 25% or greater of total energy as added sugars, adjusted mean HDL-C levels were, respectively, 58.7, 57.5, 53.7, 51.0, and 47.7 mg/dL (P<.001 for linear trend), geometric mean triglyceride levels were 105, 102, 111, 113, and 114 mg/dL (P<.001 for linear trend), and LDL-C levels modified by sex were 116, 115, 118, 121, and 123 mg/dL among women (P=.047 for linear trend). There were no significant trends in LDL-C levels among men. Among higher consumers (≥10% added sugars) the odds of low HDL-C levels were 50% to more than 300% greater compared with the reference group (<5% added sugars).
Conclusion
In this study, there was a statistically significant correlation between dietary added sugars and blood lipid levels among US adults.
doi:10.1001/jama.2010.449
PMCID: PMC3045262  PMID: 20407058

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