Article | Published:


Maternal metabolic factors during pregnancy predict early childhood growth trajectories and obesity risk: the CANDLE Study

International Journal of Obesity (2019) | Download Citation



We investigated the individual and additive effects of three modifiable maternal metabolic factors, including pre-pregnancy overweight/obesity, gestational weight gain (GWG), and gestational diabetes mellitus (GDM), on early childhood growth trajectories and obesity risk.


A total of 1425 mother–offspring dyads (953 black and 472 white) from a longitudinal birth cohort were included in this study. Latent class growth modeling was performed to identify the trajectories of body mass index (BMI) from birth to 4 years in children. Poisson regression models were used to examine the associations between the maternal metabolic risk factors and child BMI trajectories and obesity risk at 4 years.


We identified three discrete BMI trajectory groups, characterized as rising-high-BMI (12.6%), moderate-BMI (61.0%), or low-BMI (26.4%) growth. Both maternal pre-pregnancy obesity (adjusted relative risk [adjRR] = 1.96; 95% confidence interval [CI]: 1.36–2.83) and excessive GWG (adjRR = 1.71, 95% CI: 1.13–2.58) were significantly associated with the rising-high-BMI trajectory, as manifested by rapid weight gain during infancy and a stable but high BMI until 4 years. All three maternal metabolic indices were significantly associated with childhood obesity at age 4 years (adjRR for pre-pregnancy obesity = 2.24, 95% CI: 1.62–3.10; adjRR for excessive GWG = 1.46, 95% CI: 1.01–2.09; and adjRR for GDM = 2.14, 95% = 1.47–3.12). In addition, risk of rising-high BMI trajectory or obesity at age 4 years was stronger among mothers with more than one metabolic risk factor. We did not observe any difference in these associations by race.


Maternal pre-pregnancy obesity, excessive GWG, and GDM individually and jointly predict rapid growth and obesity at age 4 years in offspring, regardless of race. Interventions targeting maternal obesity and metabolism may prevent or slow the rate of development of childhood obesity.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Additional information

Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


  1. 1.

    Fryar C, Carroll M, Ogden C. Prevalence of overweight and obesity among children and adolescents aged 2–19 years: United States, 1963–1965 through 2013–2014. NCHS Health E-Stat. 2016.

  2. 2.

    Singh AS, Mulder C, Twisk JW, van Mechelen W, Chinapaw MJ. Tracking of childhood overweight into adulthood: a systematic review of the literature. Obes Rev. 2008;9:474–88.

  3. 3.

    Brisbois TD, Farmer AP, McCargar LJ. Early markers of adult obesity: a review. Obes Rev. 2012;13:347–67.

  4. 4.

    Lakshman R, Elks CE, Ong KK. Childhood obesity. Circulation. 2012;126:1770–9.

  5. 5.

    Dabelea D, Harrod CS. Role of developmental overnutrition in pediatric obesity and type 2 diabetes. Nutr Rev. 2013;71 Suppl 1:S62–7.

  6. 6.

    Juonala M, Magnussen CG, Berenson GS, Venn A, Burns TL, Sabin MA, et al. Childhood adiposity, adult adiposity, and cardiovascular risk factors. N Engl J Med. 2011;365:1876–85.

  7. 7.

    Baker JL, Olsen LW, Sorensen TI. Childhood body-mass index and the risk of coronary heart disease in adulthood. N Engl J Med. 2007;357:2329–37.

  8. 8.

    Umer A, Kelley GA, Cottrell LE, Giacobbi P Jr., Innes KE, Lilly CL. Childhood obesity and adult cardiovascular disease risk factors: a systematic review with meta-analysis. BMC Public Health. 2017;17:683.

  9. 9.

    Crume TL, Ogden L, Daniels S, Hamman RF, Norris JM, Dabelea D. The impact of in utero exposure to diabetes on childhood body mass index growth trajectories: the EPOCH study. J Pediatr. 2011;158:941–6.

  10. 10.

    Hammond RA, Levine R. The economic impact of obesity in the United States. Diabetes Metab Syndr Obes. 2010;3:285–95.

  11. 11.

    Cawley J. The economics of childhood obesity. Health Aff (Proj Hope). 2010;29:364–71.

  12. 12.

    Trasande L, Chatterjee S. The impact of obesity on health service utilization and costs in childhood. Obesity (Silver Spring). 2009;17:1749–54.

  13. 13.

    Nicholas LM, Morrison JL, Rattanatray L, Zhang S, Ozanne SE, McMillen IC. The early origins of obesity and insulin resistance: timing, programming and mechanisms. Int J Obes (Lond). 2016;40:229–38.

  14. 14.

    Sridhar SB, Darbinian J, Ehrlich SF, Markman MA, Gunderson EP, Ferrara A, et al. Maternal gestational weight gain and offspring risk for childhood overweight or obesity. Am J Obstet Gynecol. 2014;211:259 e251–8.

  15. 15.

    Ahmed SR, Ellah MA, Mohamed OA, Eid HM. Prepregnancy obesity and pregnancy outcome. Int J Health Sci (Qassim). 2009;3:203–8.

  16. 16.

    Kaseva N, Vaarasmaki M, Matinolli HM, Sipola-Leppanen M, Tikanmaki M, Heinonen K, et al. Pre-pregnancy overweight or obesity and gestational diabetes as predictors of body composition in offspring twenty years later: evidence from two birth cohort studies. Int J Obes (Lond). 2018;42:872–9.

  17. 17.

    Lau EY, Liu J, Archer E, McDonald SM, Liu J. Maternal weight gain in pregnancy and risk of obesity among offspring: a systematic review. J Obes. 2014;2014:524939.

  18. 18.

    Aris IM, Chen LW, Tint MT. Body mass index trajectories in the first two years and subsequent childhood cardio-metabolic outcomes: a prospective multi-ethnic Asian cohort study. Sci Rep. 2017;7:8424.

  19. 19.

    Ziyab AH, Karmaus W, Kurukulaaratchy RJ, Zhang H, Arshad SH. Developmental trajectories of body mass index from infancy to 18 years of age: prenatal determinants and health consequences. J Epidemiol Community Health. 2014;68:934–41.

  20. 20.

    Montazeri P, Vrijheid M, Martinez D, Basterrechea M, Fernandez-Somoano A, Guxens M, et al. Maternal metabolic health parameters during pregnancy in relation to early childhood BMI trajectories. Obesity (Silver Spring). 2018;26:588–96.

  21. 21.

    Naja F, Hwalla N, Itani L, Karam S, Sibai AM, Nasreddine L. A Western dietary pattern is associated with overweight and obesity in a national sample of Lebanese adolescents (13–19 years): a cross-sectional study. Br J Nutr. 2015;114:1909–19.

  22. 22.

    Isong IA, Rao SR, Bind MA, Avendano M, Kawachi I, Richmond TK. Racial and ethnic disparities in early childhood obesity. Pediatrics. 2018;141:e20170865.

  23. 23.

    Widen EM, Whyatt RM, Hoepner LA, Mueller NT, Ramirez-Carvey J, Oberfield SE, et al. Gestational weight gain and obesity, adiposity and body size in African-American and Dominican children in the Bronx and Northern Manhattan. Matern Child Nutr. 2016;12:918–28.

  24. 24.

    Heerman WJ, Bian A, Shintani A, Barkin SL. Interaction between maternal prepregnancy body mass index and gestational weight gain shapes infant growth. Acad Pediatr. 2014;14:463–70.

  25. 25.

    Mehta SH, Kruger M, Sokol RJ. Is maternal diabetes a risk factor for childhood obesity? J Matern-Fetal Neonatal Med. 2012;25:41–4.

  26. 26.

    Whitaker RC. Predicting preschooler obesity at birth: the role of maternal obesity in early pregnancy. Pediatrics. 2004;114:e29–36.

  27. 27.

    Palmer FB, Anand KJ, Graff JC, Murphy LE, Qu Y, Volgyi E, et al. Early adversity, socioemotional development, and stress in urban 1-year-old children. J Pediatr. 2013;163:1733–9.

  28. 28.

    Tylavsky FA, Kocak M, Murphy LE, Graff JC, Palmer FB, Volgyi E, et al. Gestational vitamin 25(OH)D status as a risk factor for receptive language development: a 24-month, longitudinal, observational study. Nutrients. 2015;7:9918–30.

  29. 29.

    Volgyi E, Carroll KN, Hare ME, Ringwald-Smith K, Piyathilake C, Yoo W, et al. Dietary patterns in pregnancy and effects on nutrient intake in the Mid-South: the Conditions Affecting Neurocognitive Development and Learning in Early Childhood (CANDLE) study. Nutrients. 2013;5:1511–30.

  30. 30.

    Rasmussen KM, Catalano PM, Yaktine AL. New guidelines for weight gain during pregnancy: what obstetrician/gynecologists should know. Curr Opin Obstet Gynecol. 2009;21:521–6.

  31. 31.

    Colon-Ramos U, Racette SB, Ganiban J, Nguyen TG, Kocak M, Carroll KN, et al. Association between dietary patterns during pregnancy and birth size measures in a diverse population in Southern US. Nutrients. 2015;7:1318–32.

  32. 32.

    Fernandez-Barres S, Romaguera D, Valvi D, Martinez D, Vioque J, Navarrete-Munoz EM, et al. Mediterranean dietary pattern in pregnant women and offspring risk of overweight and abdominal obesity in early childhood: the INMA birth cohort study. Pediatr Obes. 2016;11:491–9.

  33. 33.

    Grummer-Strawn LM, Reinold C, Krebs NF. Use of World Health Organization and CDC growth charts for children aged 0–59 months in the United States. MMWR Recomm Rep. 2010;59:1–15.

  34. 34.

    McCutcheon AL. Latent class analysis. Newbury Park, CA: SAGE Publications; 1987.

  35. 35.

    Jones B, Nagi ND, Roeder K. SAS Procedure based on mixture models for estimating developmental trajectories. Sociol Methods Res. 2001;29:374–93.

  36. 36.

    Wacholder S. Binomial regression in GLIM: estimating risk ratios and risk differences. Am J Epidemiol. 1986;123:174–84.

  37. 37.

    McNutt LA, Wu C, Xue X, Hafner JP. Estimating the relative risk in cohort studies and clinical trials of common outcomes. Am J Epidemiol. 2003;157:940–3.

  38. 38.

    Moschonis G, Kalliora AC, Costarelli V, Papandreou C, Koutoukidis D, Lionis C, et al. Identification of lifestyle patterns associated with obesity and fat mass in children: the Healthy Growth Study. Public Health Nutr. 2014;17:614–24.

  39. 39.

    Giles LC, Whitrow MJ, Davies MJ, Davies CE, Rumbold AR, Moore VM. Growth trajectories in early childhood, their relationship with antenatal and postnatal factors, and development of obesity by age 9 years: results from an Australian birth cohort study. Int J Obes (Lond). 2015;39:1049–56.

  40. 40.

    Liu JX, Liu JH, Frongillo EA, Boghossian NS, Cai B, Hazlett LJ. Body mass index trajectories during infancy and pediatric obesity at 6 years. Ann Epidemiol. 2017;27:708–15.

  41. 41.

    Rzehak P, Oddy WH, Mearin ML, Grote V, Mori TA, Szajewska H, et al. Infant feeding and growth trajectory patterns in childhood and body composition in young adulthood. Am J Clin Nutr. 2017;106:568–80.

  42. 42.

    Peneau S, Giudici KV, Gusto G, Goxe D, Lantieri O, Hercberg S, et al. Growth trajectories of body mass index during childhood: associated factors and health outcome at adulthood. J Pediatr. 2017;186:64–71.

  43. 43.

    Pryor LE, Tremblay RE, Boivin M, Touchette E, Dubois L, Genolini C, et al. Developmental trajectories of body mass index in early childhood and their risk factors: an 8-year longitudinal study. Arch Pediatr Adolesc Med. 2011;165:906–12.

  44. 44.

    Zhang J, Wang H, Wang Y, Xue H, Wang Z, Du W, et al. Dietary patterns and their associations with childhood obesity in China. Br J Nutr. 2015;113:1978–84.

  45. 45.

    DeSisto CL, Kim SY, Sharma AJ. Prevalence estimates of gestational diabetes mellitus in the United States, Pregnancy Risk Assessment Monitoring System (PRAMS), 2007–2010. Prev Chronic Dis. 2014;11:E104.

  46. 46.

    Bider-Canfield Z, Martinez MP, Wang X, Yu W, Bautista MP, Brookey J, et al. Maternal obesity, gestational diabetes, breastfeeding and childhood overweight at age 2 years. Pediatr Obes. 2017;12:171–8.

  47. 47.

    Robinson SM, Crozier SR, Harvey NC, Barton BD, Law CM, Godfrey KM, et al. Modifiable early-life risk factors for childhood adiposity and overweight: an analysis of their combined impact and potential for prevention. Am J Clin Nutr. 2015;101:368–75.

  48. 48.

    Anzman SL, Rollins BY, Birch LL. Parental influence on children’s early eating environments and obesity risk: implications for prevention. Int J Obes (Lond). 2010;34:1116–24.

  49. 49.

    Pitkin RM. Nutritional support in obstetrics and gynecology. Clin Obstet Gynecol. 1976;19:489–513.

  50. 50.

    Nelson SM, Matthews P, Poston L. Maternal metabolism and obesity: modifiable determinants of pregnancy outcome. Hum Reprod Update. 2010;16:255–75.

  51. 51.

    Karachaliou M, Georgiou V, Roumeliotaki T, Chalkiadaki G, Daraki V, Koinaki S, et al. Association of trimester-specific gestational weight gain with fetal growth, offspring obesity, and cardiometabolic traits in early childhood. Am J Obstet Gynecol. 2015;212:502.e501–14.

  52. 52.

    Alfaradhi MZ, Ozanne SE. Developmental programming in response to maternal overnutrition. Front Genet. 2011;2:27.

  53. 53.

    Wrotniak BH, Shults J, Butts S, Stettler N. Gestational weight gain and risk of overweight in the offspring at age 7 y in a multicenter, multiethnic cohort study. Am J Clin Nutr. 2008;87:1818–24.

  54. 54.

    Dabelea D. The predisposition to obesity and diabetes in offspring of diabetic mothers. Diabetes Care. 2007;30 Suppl 2:S169–74.

  55. 55.

    Ge ZJ, Zhang CL, Schatten H, Sun QY. Maternal diabetes mellitus and the origin of non-communicable diseases in offspring: the role of epigenetics. Biol Reprod. 2014;90:139.

  56. 56.

    Okubo H, Crozier SR, Harvey NC, Godfrey KM, Inskip HM, Cooper C, et al. Diet quality across early childhood and adiposity at 6 years: the Southampton Women’s Survey. Int J Obes (Lond). 2015;39:1456–62.

  57. 57.

    Wright CS, Weiner M, Localio R, Song L, Chen P, Rubin D. Misreport of gestational weight gain (GWG) in birth certificate data. Matern Child Health J. 2012;16:197–202.

  58. 58.

    McClure CK, Bodnar LM, Ness R, Catov JM. Accuracy of maternal recall of gestational weight gain 4 to 12 years after delivery. Obesity (Silver Spring). 2011;19:1047–53.

Download references


The CANDLE study was supported by the Urban Child Institute, the University of Tennessee Heath Science Center, and NIH (1R01HL109977) grants.

Author information


  1. Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, 38163, USA

    • Zunsong Hu
    • , Frances A. Tylavsky
    • , Mehmet Kocak
    • , Jay H. Fowke
    •  & Qi Zhao
  2. Departments of Pediatrics and Physiology, University of Tennessee Health Science Center, Memphis, TN, 38103, USA

    • Joan C. Han
  3. Children’s Foundation Research Institute, Le Bonheur Children’s Hospital, Memphis, TN, 38103, USA

    • Joan C. Han
  4. Department of Pediatrics, Center for Biomedical Informatics, University of Tennessee Health Science Center, Memphis, TN, 38103, USA

    • Robert L. Davis
  5. Department of Psychiatry, University of California San Francisco, San Francisco, CA, 94118, USA

    • Kaja Lewinn
  6. Departments of Pediatrics and Psychiatry, University of California San Francisco, San Francisco, CA, 94118, USA

    • Nicole R. Bush


  1. Search for Zunsong Hu in:

  2. Search for Frances A. Tylavsky in:

  3. Search for Joan C. Han in:

  4. Search for Mehmet Kocak in:

  5. Search for Jay H. Fowke in:

  6. Search for Robert L. Davis in:

  7. Search for Kaja Lewinn in:

  8. Search for Nicole R. Bush in:

  9. Search for Qi Zhao in:

Conflict of interest

The authors declare that they have no conflict of interest.

Corresponding author

Correspondence to Qi Zhao.

Supplementary information

About this article

Publication history