Getting under the skin: children's health disparities as embodiment of social class

Social class gradients in children’s health and development are ubiquitous across time and geography. The authors develop a conceptual framework relating three actions of class—material allocation, salient group identity, and inter-group conflict—to the reproduction of class-based disparities in child health. A core proposition is that the actions of class stratification create variation in children’s mesosystems and microsystems in distinct locations in the ecology of everyday life. Variation in mesosystems (e.g., health care, neighborhoods) and microsystems (e.g., family structure, housing) become manifest in a wide variety of specific experiences and environments that produce the behavioral and biological antecedents to health and disease among children. The framework is explored via a review of theoretical and empirical contributions from multiple disciplines and high-priority areas for future research are highlighted

Pre-pregnancy body mass index and gestational weight gain and their effects on pregnancy and birth outcomes: a cohort study in West Sumatra, Indonesia

Background: Indonesia has a considerably high incidence of maternal and infant mortality. The country has however been experiencing a social and economic transition, influencing its general population demographics and nutritional status including the state of health and nutrition of pregnant women. This study aimed to explore body mass index (BMI) and gestational weight gain (GWG), and their relationship with pregnancy outcomes in a sample of Indonesian pregnant women. Methods: This observational cohort study included a total of 607 pregnant women who were recruited in 2010 from maternity clinics in Western Sumatra, Indonesia. Multiple logistic and regression analyses were undertaken to compare pregnancy and birth outcomes for different BMI and GWG, using normal weight women and women with a recommended weight gain as the referent groups. Results: The prevalence of underweight (BMI < 18.5 kg/m2) in pregnancy was high at 20.1%; while 21.7% of women were overweight (BMI: 23.0–27.4 kg/m2) and 5.3% obese (BMI ≥ 27.5 kg/m2) using the Asian BMI classifications. The incidence of overweight (BMI: 25.0–29.9 kg/m2) and obese (BMI ≥ 30.0 kg/m2) according to the international BMI classifications were 13.5% and 1.1% respectively. The majority of women gained inadequate weight in pregnancy compared to the Institute of Medicine (IOM)recommendations, especially those who had a normal BMI. Birthweight adjusted mean difference aMD (95% confidence interval) 205 (46,365) and the odds of macrosomia adjusted odds ratio aOR 13.46 (2.32–77.99) significantly increased in obese women compared to those with a normal BMI. Birthweight aMD -139 (−215, −64) significantly decreased in women with inadequate GWG compared to those with recommended GWG, while SGA aOR 5.44 (1.36, 21.77) and prematurity aOR 3.55 (1.23, 10.21) increased. Conclusions: Low nutritional status and inadequate GWG remain a cause for concern in these women. The higher odds of macrosomia with increasing maternal BMI and higher odds of prematurity and small for gestational age infants with inadequate weight gain also require attention. Research and practice recommendations: Urgent attention is required by researchers, policy makers and decision makers to facilitate development of culturally sensitive interventions to enhance nutritional status and health of mothers and babies, in an area known for its high incidence of maternal and neonatal mortality. Keywords: Maternal BMI, Gestational weight gain, Pregnancy outcomes, Birthweight, Indonesia, Cohort stud

Gestational Weight Gain and Body Mass Index in Children: Results from Three German Cohort Studies

Previous studies suggested potential priming effects of gestational weight gain (GWG) on offspring's body composition in later life. However, consistency of these effects in normal weight, overweight and obese mothers is less clear. We combined the individual data of three German cohorts and assessed associations of total and excessive GWG (as defined by criteria of the Institute of Medicine) with offspring's mean body mass index (BMI) standard deviation scores (SDS) and overweight at the age of 5-6 years (total: n = 6,254). Quantile regression was used to examine potentially different effects on different parts of the BMI SDS distribution. All models were adjusted for birth weight, maternal age and maternal smoking during pregnancy and stratified by maternal pre-pregnancy weight status. In adjusted models, positive associations of total and excessive GWG with mean BMI SDS and overweight were observed only in children of non- overweight mothers. For example, excessive GWG was associated with a mean increase of 0.08 (95% CI: 0.01, 0.15) units of BMI SDS (0.13 (0.02, 0.24) kg/m(2) of 'real' BMI) in children of normal-weight mothers. The effects of total and excessive GWG on BMI SDS increased for higher- BMI children of normal-weight mothers. Increased GWG is likely to be associated with overweight in offspring of non-overweight mothers

Obesity and Weight Gain in Pregnancy and Postpartum: An Evidence Review of Lifestyle Interventions to Inform Maternal and Child Health Policies

Background: Maternal obesity, excessive gestational weight gain (GWG) and post-partum weight retention (PPWR) constitute new public health challenges, due to the association with negative short- and long-term maternal and neonatal outcomes. The aim of this evidence review was to identify effective lifestyle interventions to manage weight and improve maternal and infant outcomes during pregnancy and postpartum. Methods: A review of systematic reviews and meta-analyses investigating the effects of lifestyle interventions on GWG or PPWR was conducted (Jan 2009-2018) via electronic searches in the databases Medline, Pubmed, Web of Science and Cochrane Library using all keywords related to obesity/weight gain/loss, pregnancy or postpartum and lifestyle interventions;15 relevant reviews were selected. Results: In healthy women from all BMI classes, diet and physical activity interventions can decrease: GWG (mean difference -1.8 to -0.7 kg, high to moderate-quality evidence); the risks of GWG above the IOM guidelines (risk ratio [RR] 0.72 to 0.80, high to low-quality evidence); pregnancy-induced hypertension (RR 0.30 to 0.66, low to very low-quality evidence); cesarean section (RR 0.91 to 0.95; high to moderate-quality evidence) and neonatal respiratory distress syndrome (RR 0.56, high-quality evidence); without any maternal/fetal/neonatal adverse effects. In women with overweight/obesity, multi-component interventions can decrease: GWG (-0.91 to -0.63 kg, moderate to very low-quality evidence); pregnancy-induced hypertension (RR 0.30 to 0.66, low-quality evidence); macrosomia (RR 0.85, 0.73 to 1.0, moderate-quality evidence) and neonatal respiratory distress syndrome (RR 0.47, 0.26 to 0.85, moderate-quality evidence). Diet is associated with greater reduction of the risks of GDM, pregnancy-induced hypertension and preterm birth, compared with any other intervention. After delivery, combined diet and physical activity interventions reduce PPWR in women of any BMI (-2.57 to -2.3 kg, very low quality evidence) or with overweight/obesity (-3.6 to -1.22, moderate to very low-quality-evidence), but no other effects were reported. Conclusions: Multi-component approaches including a balanced diet with low glycaemic load and light to moderate intensity physical activity, 30-60 min per day 3-5 days per week, should be recommended from the first trimester of pregnancy and maintained during the postpartum period. This evidence review should help inform recommendations for health care professionals and women of child-bearing age

Socioeconomic disadvantage in childhood as a predictor of excessive gestational weight gain and obesity in midlife adulthood

BACKGROUND: Lower childhood socioeconomic position is associated with greater risk of adult obesity among women, but not men. Pregnancy-related weight changes may contribute to this gender difference. The objectives of this study were to determine the associations between: 1. childhood socioeconomic disadvantage and midlife obesity; 2. excessive gestational weight gain (GWG) and midlife obesity; and 3. childhood socioeconomic disadvantage and excessive GWG, among a representative sample of childbearing women. METHODS: We constructed marginal structural models for seven measures of childhood socioeconomic position for 4780 parous women in the United States, using National Longitudinal Survey of Youth (1979–2010) data. Institute of Medicine definitions were used for excessive GWG; body mass index ≥30 at age 40 defined midlife obesity. Analyses were separated by race/ethnicity. Additionally, we estimated controlled direct effects of childhood socioeconomic disadvantage on midlife obesity under a condition of never gaining excessively in pregnancy. RESULTS: Low parental education, but not other measures of childhood disadvantage, was associated with greater midlife obesity among non-black non-Hispanic women. Among black and Hispanic mothers, childhood socioeconomic disadvantage was not consistently associated with midlife obesity. Excessive GWG was associated with greater midlife obesity in all racial/ethnic groups. Childhood socioeconomic disadvantage was not statistically significantly associated with excessive GWG in any group. Controlled direct effects were not consistently weaker than total effects. CONCLUSIONS: Childhood socioeconomic disadvantage was associated with adult obesity, but not with excessive gestational weight gain, and only for certain disadvantage measures among non-black non-Hispanic mothers. Prevention of excessive GWG may benefit all groups through reducing obesity, but excessive GWG does not appear to serve as a mediator between childhood socioeconomic position and adult obesity in women

Racial/Ethnic Disparities in Inadequate Gestational Weight Gain Differ by Pre-pregnancy Weight

OBJECTIVES: Pre-pregnancy body mass index (BMI) varies by race/ethnicity and modifies the association between gestational weight gain (GWG) and adverse pregnancy outcomes, which disproportionately affect racial/ethnic minorities. Yet studies investigating whether racial/ethnic disparities in GWG vary by pre-pregnancy BMI are inconsistent, and none studied nationally representative populations. METHODS: Using categorical measures of GWG adequacy based on Institute of Medicine recommendations, we investigated whether associations between race/ethnicity and GWG adequacy were modified by pre-pregnancy BMI [underweight (<18.5kg/m(2)), normal weight (18.5-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)), or obese (≥30.0 kg/m(2)) ] among all births to Black, Hispanic, and White mothers in the 1979 USA National Longitudinal Survey of Youth cohort (n=6849 pregnancies; range=1-10). We used generalized estimating equations, adjusted for marital status, parity, smoking during pregnancy, gestational age, and multiple measures of socioeconomic position. RESULTS: Effect measure modification between race/ethnicity and pre-pregnancy BMI was significant for inadequate GWG (Wald test p-value=0.08). Normal weight Black (Risk Ratio (RR)=1.34, 95% confidence interval (CI): 1.18, 1.52) and Hispanic women (RR=1.33, 95%CI: 1.15, 1.54) and underweight Black women (RR=1.38; 95% CI: 1.07, 1.79) experienced an increased risk of inadequate GWG compared to Whites. Differences in risk of inadequate GWG between minority women, compared to White women, were not significant among overweight and obese women. Effect measure modification between race/ethnicity and pre-pregnancy BMI was not significant for excessive GWG. CONCLUSIONS: The magnitude of racial/ethnic disparities in inadequate GWG appears to vary by pre-pregnancy weight class, which should be considered when designing interventions to close racial/ethnic gaps in healthy GWG

Economic perturbations and fetal growth: A multilevel analysis of exposure to labor market insecurity during gestation and birth weight for gestational age

Economic perturbations and fetal growth: A multilevel analysis of exposure to labor market insecurity during gestation and birth weight for gestational age byClaire E. Margerison-ZilkoDoctor of Philosophy in EpidemiologyUniversity of California, BerkeleyProfessor Jennifer Ahern, ChairBackground. Epidemiologic research has made important strides in identifying individual-level risk factors for adverse birth outcomes such as low birth weight and preterm birth, which carry high clinical, social, and economic costs. Despite this accumulated knowledge, we remain unable to explain differences in the distribution of birth outcomes between populations and within populations across space and time, suggesting the need to consider macro-level, ecologic determinants of birth outcomes. In this dissertation, I developed a conceptual model based on ecologic and evolutionary theory and research that proposes that unexpected changes to the human ecology, i.e. perturbations, may result in unexpected behavioral and biological responses in humans and that such responses will be conserved by natural selection if they are adaptive. Based on this framework, I hypothesized that reductions in fetal growth would occur in response to maternal exposure to ecological perturbations--specifically, perturbations to labor market security--during gestation.Methods. I examined the association between maternal exposure to state-level labor market perturbations during each trimester of gestation and fetal growth, as measured by birth weight for gestational age percentile. The study population included 6,715 gestations and births between 1982 and 2000 to women enrolled in the National Longitudinal Survey of Youth 1979 (NLSY79). I calculated birth weight for gestational age percentiles using national reference data and categorized births &lt;10th percentile as small for gestational age (SGA).I defined perturbations to labor market security as months in which the state unemployment rate was higher than its statistically expected value (i.e., unexpectedly high labor market insecurity) and months in which the state unemployment rate was lower than its statistically expected value (i.e., unexpectedly high security). I derived statistically expected values using ARIMA modeling methods to account for autocorrelation. Gestations in the NLSY79 were classified as either exposed or unexposed to labor market insecurity or security in the first, second, and third trimester if one of these labor market perturbations occurred in the maternal state of residence during that trimester.I used linear and logistic regression models to examine the association between labor market perturbations in each trimester and birth weight percentile and odds of SGA. I also examined whether any observed associations differed by maternal race/ethnicity, childhood socioeconomic status, educational attainment, marital status, employment status, or poverty status. Finally, I explored whether any observed associations were mediated by individual economic change (i.e., changes in maternal employment status or household income) or maternal pregnancy behaviors (i.e., smoking, first trimester utilization of prenatal care, or net gestational weight gain). If associations were mediated by one these factors, I calculated the proportion of the total association explained by that factor.Results. Exposure to labor market insecurity in the first trimester was significantly associated with a decrease in birth weight for gestational age of 4.05 percentile points (95% CI = -6.87, -1.22) and higher odds of SGA (OR = 1.50, 95% CI = 1.21, 1.86). Exposure to labor market insecurity in the second and third trimesters was not significantly associated with either outcome. Exposure to labor market security was not associated with birth weight for gestational age percentile or SGA. The association between exposure to labor market insecurity in the first trimester and birth weight percentile differed significantly by maternal childhood SES, educational attainment, and employment status but not by race/ethnicity, marital status, or poverty status. Exposure to labor market insecurity in the first trimester was associated with decreases in birth weight percentile of 5.52 (95% CI = -10.0, -1.04) and 8.66 points (95% CI = -14.04, -3.29) among women with average or high childhood SES, respectively, while the association was not significant among women with low childhood SES. Exposure to labor market insecurity in the first trimester was associated with a decrease in birth weight percentile of 9.22 points (95% CI = -15.77, -2.88) among women with &lt;12 years educational attainment, while the association was not significant among women with 12 years or &gt;12 years educational attainment. Exposure to labor market insecurity was associated with a decrease in birth weight percentile of 7.10 points (95% CI = -12.33, -1.87) and 10.27 points (95% CI = (-18.82, -1.71) among women keeping house and out of the labor force, respectively, while the association was not significant among employed and unemployed women.My exploration of mediation by individual economic change and maternal pregnancy behaviors found that approximately 11% of the association between exposure to labor market insecurity in the first trimester and birth weight percentile was explained by net maternal gestational weight gain. The association also differed significantly by maternal smoking, with the association only significant among smokers. No other individual economic change or maternal pregnancy behaviors mediated greater than one percent of the association.Conclusions. Findings support my hypothesis that fetal growth responds to a contemporary ecological perturbation, i.e., unexpectedly high labor market insecurity. Exposure to this perturbation appears to have more impact on fetal growth if it occurs in the first trimester of gestation. The finding that associations between exposure to labor market insecurity and birth weight percentile were stronger among women with high childhood SES, &lt;12 years education, and those keeping house or out of the labor force suggests that these women may be more vulnerable to economic perturbations. Although further research on mediation is needed, initial findings suggest that maternal gestational weight gain may represent one pathway through which economic perturbations affect fetal growth