Perinatal maternal and child growth mediate the association between maternal education and children’s overweight/obesity in Europe: The Feel4Diabetes-study

Perinatal maternal and child growth mediate the association between maternal education and children’s overweight/obesity in Europe: The Feel4Diabetes-study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Perinatal maternal and child growth mediate the association between maternal education and children’s overweight/obesity in Europe: The Feel4Diabetes-study Yannis Manios, Aikaterini Kontochristopoulou, Kalliopi Karatzi, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6226046/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background/Objectives: Early-life factors and maternal education interact with childhood overweight/obesity through pathways that remain unclear. Our aim was to investigate the predominant perinatal correlates of childhood overweight/obesity and their mediating effects on the association between maternal education and children's overweight/obesity. Subjects/Methods: In this cross-sectional study the total sample included 12211 children (4–12 years-old) from low socioeconomic status (SES) regions in six European countries, with 2663 having complete data for analysis. Interventions/methods: All measurements were carried out during August-September 2016. Children’s anthropometrics were measured and parents self-reported all other data (perinatal/ sociodemographic) via questionnaires. All variables were adjusted for maternal education, sex and age (p<0.05). Results: Maternal overweight (OR 1.54 (95% CI 1.19–1.99)), obesity (OR 2.51 (95% CI 1.57–4.00)), pre-pregnancy diabetes (OR 4.92 (95% CI 1.31–18.38)), smoking during pregnancy (OR 1.59 (95% CI 1.20–2.10)) and excessive gestational weight gain (OR 2.00 (95% CI 2.59–2.53)) were associated with childhood overweight/obesity. Children born small-for-gestational-age (OR 0.57 (95% CI 0.36–0.89)) had lower odds, whereas those born long-for-gestational-age (OR 1.49 (95% CI 1.15–1.92)) had higher odds of childhood overweight/obesity. Rapid weight gain during the first 6 months was positively associated (OR 1.30 (95% CI 1.04–1.63)) with overweight/obesity in children. Maternal pre-pregnancy weight status, rapid weight gain in the first 6 months and gestational weight gain mediated by 16.6%, 8.4%, and 7.8%, respectively, the maternal education-child obesity link. Conclusion: Perinatal factors play a crucial role in the onset of childhood obesity, and evidence suggests their association with maternal education. Families with lower education should be targeted, aiming to raise awareness of health issues related to maternal/children’s healthy lifestyle and improve nutrition knowledge, aiming to ensure healthy maternal weight prior to and during pregnancy and normal infant growth. Health sciences/Health care/Paediatrics Health sciences/Health care/Public health/Epidemiology Obesity childhood perinatal pregnancy education Figures Figure 1 INTRODUCTION Childhood obesity, a precursor of adult obesity, often begins in the pre-pregnancy or pregnancy period and remains a significant public health challenge. 1 In 2022, 37 million children under 5 years of age and over 390 million aged 5–19 years were classified as overweight, while 160 million lived with obesity. Once predominantly observed in high-income countries, childhood obesity is now increasing in low- and middle-income nations. 1 Previous studies underscore its multifactorial origins, with numerous risk factors, often starting in the perinatal period, contributing to its development. 2 , 3 Perinatal factors, which influence infants during the intrauterine period and infancy, can induce lasting physiological changes known as metabolic programming, affecting weight status both in early childhood and later in life. The developmental origins of health and disease hypothesis suggests that certain environmental exposures during fetal and early life periods can have long-term implications for health and disease risk. 4 Early-life interventions and prenatal care are needed to promote long-term health and disease prevention. 4 However, perinatal factors are also shaped by sociodemographic factors, with maternal pre-pregnancy obesity, excessive gestational weight gain, smoking during pregnancy, rapid infant weight gain and early solid food introduction being affected by factors such as maternal education, family economic status and ethnicity. 5 – 6 Research on the interplay between perinatal factors, sociodemographic influences, and childhood overweight/obesity in Europe remains limited, with most studies focusing on single countries. Few studies have examined how perinatal factors mediate the relationship between sociodemographic determinants and children's weight. Maternal education, a key sociodemographic factor, is a significant predictor of childhood obesity, shaping health behaviors and environmental influences. 7 , 8 Higher maternal education is associated with lower risk of childhood obesity potentially due to positive parenting practices, improved home/environmental management, and reduced exposure to socio-economic disadvantages. 9 Conversely, lower maternal education is associated with higher rates of smoking during pregnancy, limited breastfeeding, food insecurity and stress related to family dynamics and financial instability. 10 – 12 Nevertheless, most evidence comes from individual countries (Western and Northern Europe), limiting broader applicability. 7 – 9 Recognizing this gap, our study investigates these associations across six European countries, considering socioeconomic status(SES), culture, health behaviors, physical activity, and perceptions of healthy weight, to assess whether perinatal factors mediate the maternal education–childhood obesity link. MATERIALS/SUBJECTS & METHODS Study design and sampling procedure The current study considered the baseline data of the Feel4Diabetes-study (National Clinical Trial number, NCT:02393872) which included a large school and community-based intervention. The Feel4Diabetes study, which had a cluster-randomized design, aimed to promote a healthy lifestyle among school children and their parents including healthy eating and enhancing physical activity. It intended to alleviate the negative outcomes of obesity and obesity-related metabolic risk factors in low socioeconomic status (SES) families in Europe. The recruitment of this study targeted families from “vulnerable” social groups across six European countries. “Vulnerable” groups were defined as those from low-/middle- income countries (Bulgaria, Hungary), low socio-economic areas in high-income countries (Belgium, Finland) and countries under austerity measures (Greece, Spain). In Bulgaria and Hungary, all areas within the selected provinces were considered “vulnerable” and eligible to participate in the study. In Greece, Spain, Finland and Belgium, the municipalities/school districts/other equivalent units in the selected provinces were grouped in tertiles according to socio-economic indices retrieved from official resources and authorities (e.g. in Greece information was retrieved from the Hellenic Statistical Authority) with “vulnerable” areas randomly selected only from the tertile with the lowest education level or the highest unemployment rate. After approval was obtained from the local authorities (Ethics Committees, Ministries, Municipalities, etc.) lists of schools in these vulnerable areas were created, and primary schools were randomly selected to meet recruitment goals. This sample included children from the first three grades of compulsory education. 10 We focused on low SES areas, where children face a significantly elevated obesity risk compared with their wealthier counterparts. 11 Emerging research indicates that the SES–childhood obesity link is intensifying, with an increasing disparity in obesity rates between low- and high-SES groups. 11,12 In many developed countries, childhood obesity rates have stabilized or declined among higher SES groups, whereas they have risen among lower-SES groups. 13-15 These trends underscore the need for targeted interventions in low-SES communities. The study was designed in 2015, with recruitment starting in January 2016. The initial measurements took place between April and June whereas in Finland, Hungary and Bulgaria they occurred between August and September 2016. 10 The total sample included 12211 children from six European countries, with 2663 having complete data for analysis. Ethical approvals and consent forms The Feel4Diabetes study adheres to the Helsinki Declaration and the Council of Europe conventions on human rights and biomedicine. Ethical approval was obtained from relevant ethics committees and local authorities in all participating countries. Parents/guardians provided written informed consent before participation. Further details on the approvals are available elsewhere. 1 0 MEASUREMENTS Anthropometrics Trained research assistants conducted all the anthropometric measurements via standardized procedures and calibrated portable equipment. 16 Body weight was measured to the nearest 0.1kg via electronic scales (SECA 813), with children in light clothing and without shoes. Height was measured to the nearest 0.1cm using a portable stadiometer (SECA 217), with the children barefoot, and positioned according to the Frankfurt horizontal plane. Measurements were taken twice by dyads of researchers. A third measurement was taken if discrepancies exceeded 100g for weight or 1cm for height. Body Mass Index (BMI) was calculated as weight(kg) divided by height squared(m 2 ), with obesity defined using sex- and age-specific BMI cutoffs of the International Obesity Task Force. 17 Perinatal data A structured questionnaire was developed to collect children’s perinatal data from parents via schools, based on established links with childhood obesity in existing literature. It included information from children’s medical records (e.g., children’s body weight and length at birth and six months) 2,18-20 and information regarding (a) maternal age at birth, stratified into 30 years; (b) maternal pre-pregnancy BMI, calculated based on the mother’s self-reported weight pre-pregnancy and current height (categorized as underweight, normal-weight, overweight, or obesity according to the World Health Organization cutoffs) 21 ; (c) self-reported gestational weight gain, categorized as less, within, or above the weight gain recommended by the Institute of Medicine 22 ; (d) maternal smoking during pregnancy categorized as smoking during any trimester or non-smoking throughout pregnancy; (e) maternal diabetes during pregnancy, categorized as mothers with pre-existing or gestational diabetes and those with a normal glycemic profile; (f) birthweight and gestational age that were used to classify infants as small for gestational age (SGA<10th percentile), appropriate for gestational age (AGA, 10–89th percentile), or large for gestational age (LGA≥90th percentile) 23,24 ; (g) children’s growth from birth to six months, based on weight-for-length z-scores (Δ z-score) used to classify growth velocity as slow (Δ z-score0.67). 25,26 Regarding growth assessment, although the change in weight-for-age was used in existing tools, we assessed the change in weight-for-length in our analysis, since it was more strongly associated with the outcome, as also reported elsewhere 27 ; (h) breast feeding: exclusive or non-exclusive during the first six months and never breastfed; and (i) time of introduction of solids, categorized as before 4 months, at 4–6 months, or after 6 months. Sociodemographic data Standardized self-reported questionnaires were used for all study participants aiming to gather information on basic sociodemographic characteristics (date of birth, ethnicity, maternal education level). 28 Maternal education that was dichotomized into ≤14 and >14 years, considering that >14 years suggests attendance of higher education (e.g., bachelor’s program). This questionnaire was also developed and administered to parents via schools. Statistical methods Continuous variables are presented as means ± standard deviations and categorical values as proportions (%). The normality of distribution of variables was determined by the Kolmogorov–Smirnov test and histograms. Univariate logistic regression was used to analyze the associations between perinatal factors (independent variables) and childhood overweight/obesity (dependent variable). Significant factors were further assessed via multivariable logistic regression, adjusting for child age, sex, maternal education, and non-significant perinatal factors from the univariate logistic regression. The mediation analysis tested whether perinatal factors mediated the link between maternal education and childhood overweight/obesity, using one exposure variable (i.e., maternal education) and children’s overweight/obesity as the main outcome. Statistical analysis was performed via STATA statistics/Data Analysis, (College Station,Texas,USA) version 15.1. Level of statistical significance was set at p < 0.05. RESULTS The analysis included data from 2,663 children aged 4-12 years, with 49.4% of whom were boys. Among the participants, 40.6% were from low-income countries, 32.5% were from countries under economic crisis, and 26.9% were from high-income countries. Overall, 18% were children with overweight and 7.5% with obesity. Study and perinatal characteristics are detailed in Tables 1 and 2. Univariate analysis Table 2 presents the univariate analysis results, showing significant associations between maternal pre-pregnancy factors and childhood overweight/obesity. Maternal overweight (OR 1.94 (95%CI 1.65–2.29)) and obesity (OR 3.27 (95%CI 2.51–4.26)) increased the odds of childhood overweight/obesity compared with maternal underweight/normal weight. Excessive gestational weight gain (OR 1.90 (95%CI 1.64–2.21)) also increased the odds compared with appropriate gestational weight gain. Children born SGA (OR 0.70 (95%CI 0.51–0.97)) had lower odds, whereas those born LGA (OR 1.40 (95%CI 1.19–1.64)) and those with rapid weight gain during the first 6 months (evaluated with the weight-for-height z-score (WHZ)) had higher odds (OR 1.61 (95%CI 1.36–1.91)) of overweight/obesity. No associations were found for breastfeeding and time of solid food introduction. Multivariate analysis Table 2 displays the multivariable analysis results for the variables identified as significantly associated with children's overweight/obesity in the univariate analysis, adjusted for maternal education, sex, and age. Maternal overweight (OR 1.54 (95%CI 1.19–1.99)) obesity (OR 2.51 (95%CI 1.57–4.00)), pre-pregnancy diabetes (OR 4.92 (95%CI 1.31–18.38)), smoking in pregnancy (OR 1.59 (95%CI 1.20–2.10)) and excessive gestational weight gain (OR 2.00 (95%CI 2.59–2.53)) remained significantly associated with childhood overweight/obesity. Children born SGA had lower odds (OR 0.57 (95%CI 0.36–0.89)), whereas those born LGA had higher odds (OR 1.49 (95%CI 1.15–1.92)) of childhood overweight/obesity than those born appropriate for gestational age. Rapid weight gain during the first 6 months remained positively associated (OR 1.30 (95%CI 1.04–1.63)) with childhood overweight/obesity. Mediation analysis The mediation model examined in the current study is presented in Figure 1. Table 4 shows the results derived from the mediation analysis. Maternal education was significantly associated with maternal pre-pregnancy weight status, infant weight gain in the first six months (WHZ) and gestational weight gain in path a , whereas in path b , overweight/obesity was associated with maternal pre-pregnancy weight status, gestational weight gain, infant weight gain in the first six months (WHZ) and birthweight. Finally, maternal education was significantly associated with children’s overweight/obesity (OR -0.21 (95%CI -0.28 to -0.14)) ( path c ). Path c’ which represents the direct effect of maternal education on children’s overweight/obesity was statistically significant (p=0.0001), indicating that there is partial mediation by perinatal factors. The proportion mediated by maternal pre-pregnancy weight status in the association between maternal education and children’s overweight/obesity was 16.6%, that for gestational weight gain was 7.8% and that for rapid weight gain in the first six months (WHZ) was 8.4%, whereas birthweight for gestational age did not have a significant mediating effect. DISCUSSION The present study examined the associations among perinatal factors and childhood overweight/obesity. Given that maternal education is a strong sociodemographic predictor of childhood overweight/obesity 32 this study also explored the mediating role of perinatal factors in this association. Our findings indicated that maternal pre-pregnancy overweight/obesity, pre-pregnancy diabetes, smoking during pregnancy, excessive gestational weight gain, high birthweight for gestational age and rapid weight gain in the first 6 months were significantly associated with increased odds of childhood overweight/obesity. Conversely, low birthweight for gestational age was linked to lower odds. These findings align with previous research supporting the relationship between perinatal factors and childhood overweight/obesity. 2,29,30 However, there was no significant association between breastfeeding and timing of solid food introduction with overweight/obesity, which is consistent with prior studies. The inconsistency in these associations may stem from variations in study endpoints (e.g., exclusive vs. mixed breastfeeding, milk substitutes, timing of solid food introduction), age ranges, methodologies, and sample sizes. 31 , 32 Maternal characteristics, particularly elevated pre-pregnancy BMI and excessive gestational weight gain have been strongly linked to childhood obesity. A meta-analysis of 45 studies revealed that maternal pre-pregnancy overweight/obesity doubled the odds of childhood overweight and tripled obesity odds from infancy to adolescence. 33 Another meta-analysis reported that infants born to mothers with overweight/obesity presented greater fat mass and body fat percentage than those born to mothers with normal BMI. 34 Compared with women with obesity, women with normal weight or overweight may be more susceptible to the effects of excessive weight gain during pregnancy. 19 Weight gain during early and mid-pregnancy, which primarily reflects increased maternal fat rather than fetal weight, may contribute to greater adiposity in offspring due to increased maternal fuel availability. 35 According to the IOM guidelines, excessive gestational weight gain is a recognized risk factor for childhood overweight/obesity. 36 A systematic review and meta-analysis further confirmed that excessive gestational weight gain increases the likehood of childhood obesity. 37 Previous studies have primarily focused on gestational diabetes mellitus, leaving the association between pre-gestational diabetes and childhood obesity less well understood. Research on maternal pre-pregnancy diabetes has largely focused on its links to congenital malformations, perinatal mortality and morbidity, with limited attention given to long-term childhood outcomes. One prior study examined the associations between maternal diabetes, LGA status and overweight/obesity in preschool-aged children. They revealed that the LGA risk alone (39.4%) was more than twice that of gestational diabetes alone (16.0%) or pre-existing diabetes alone (15.1%). Notably, the risk of childhood obesity was highest in LGA children born to mothers with gestational or pre-existing type 2 diabetes. 38 Our study further established a clear association between maternal pre-existing diabetes and childhood overweight/obesity, independent of other risk factors. Additionally, maternal smoking during pregnancy increased the odds of childhood overweight/obesity, a finding supported by substantial evidence. A recent meta-analysis confirmed that maternal smoking during pregnancy increased the risk of overweight/obesity in offspring. 39 Moreover, maternal smoking has a greater impact than paternal smoking, suggesting that maternal smoking has a more pronounced intrauterine effect than does paternal or household smoking. Furthermore, high birthweight for gestational age was associated with higher childhood overweight/obesity odds, whereas low birthweight was protective. Although high birthweight is a known risk factor, few studies have reported a positive link between low birthweight and obesity. Generally, SGA is defined as a birthweight below the 10th percentile and LGA as a birthweight above the 90th percentile 40 ; however these definitions can vary. 38 Such definitions are somewhat arbitrary, as both low and high birthweight are associated with future health risks. 40 A J- or U-shaped association suggests that both extremes may increase childhood obesity risk. 41 Most studies investigating obesity risk rely on weight or BMI, which might not precisely capture disparities in body composition. Limited research has examined how weight variations are distributed between fat and fat-free mass. Differences in adiposity at birth may indicate metabolic dysfunction, highlighting the importance of measuring body fat. Visceral adiposity is associated with increased cardiometabolic risk. 42 Studies employing more precise techniques like dual-energy X-ray absorptiometry and magnetic resonance imaging have produced mixed findings. 43 However, the inclusion criteria and varying birthweight cutoff points make it difficult to draw firm conclusions. A meta-​analysis that is in line with our results, reported that birthweight > 4,000g increases the risk of later obesity, whereas low (< 2,500g) and normal range (2,500-4,000g) birthweight were not related to obesity risk. 43 In this study, rapid weight gain in the first six months of life was associated with higher odds of childhood overweight/obesity. In healthy infants, weight typically decreases during the first two weeks, then increases relative to height, peaking around 6 weeks, before gradually stabilizing by six months. 44 Deviations from this growth pattern are linked to future obesity risk and adult health. 18 , 44 , 45 Infants with an earlier growth peak or fasted weight gain during the first two years are more susceptible to obesity and chronic diseases later in life. 44 Numerous studies 18 , 40 including a meta-analysis found that each 1-SD increase in weight from birth to one year doubles the risk of childhood obesity 46 underscoring the long-term impact of early weight gain. 46 , 47 Mediation analysis revealed that less educated mothers are at greater risk of having children with overweight/obesity and this association is partially mediated by maternal pre-pregnancy overweight/obesity, increased gestational weight gain and rapid infant weight gain. A lower education level contributes to maternal overweight/obesity, leading to LGA infants and creating an obesogenic environment, that promotes an increase in childhood BMI. 48 Additionally, women with lower education levels may face barriers to healthcare access, leading to inadequate monitoring of gestational weight gain and potentially suboptimal outcomes. 28 , 49 Conversely, women with higher education typically have better access to prenatal care, monitor weight gain during pregnancy and are more informed about healthy lifestyle, which may positively influence children's nutritional and feeding behaviors. 50 This knowledge could translate into better feeding practices, with a diverse and nutrient-rich diet. These mothers are less likely to overfeed their infants, thus preventing rapid growth velocity—a well-documented early risk factor for childhood obesity and related comorbidities. 47 , 48 , 50 An important strength of this study is its large sample with data from over 12211 participants across six European countries and specifically from families of low SES regions that have been previously underexplored. Lower SES is associated with unhealthy maternal behaviors including smoking, alcohol consumption, and limited prenatal care, all of which increase the risk of complications during pregnancy and childbirth. Additionally, socioeconomic disparities can affect access to nutritious food and overall dietary quality. The standardized protocols and procedures across all centers, along with objective anthropometric measurements, ensure reliable and generalizable findings. On the other hand, some of the collected data were self-reported. Although the validity and reliability of the relevant questionnaires were tested before the intervention started, this approach is prone to recall and social desirability bias. The present study is a cross-sectional secondary analysis of Feel4Diabetes intervention using only data from the baseline, therefore no inferences about causality can be made. This study revealed the significant role of perinatal factors and maternal education in childhood overweight/obesity. Specifically, maternal pre-pregnancy overweight/obesity, excessive gestational weight gain, and rapid infant growth partially mediated the inverse association between maternal education and childhood obesity. The urgent need for targeted public health interventions in lower education families is emphasized, with a focus on improving healthcare access, prenatal monitoring, and raising awareness to encourage healthy weight management and lifestyle habits. Declarations Acknowledgements The authors would like to thank the members of the Feel4Diabetes-study group: coordinator, Yannis Manios; steering committee, Yannis Manios, Greet Cardon, Jaana Lindström, Peter Schwarz, Konstantinos Makrilakis, Lieven Annemans, and Winne Ko; Harokopio University (Greece), Yannis Manios, Kalliopi Karatzi, Odysseas Androutsos, George Moschonis, Spyridon Kanellakis, Christina Mavrogianni, Konstantina Tsoutsoulopoulou, Christina Katsarou, Eva Karaglani, Irini Qira, Efstathios Skoufas, Konstantina Maragkopoulou, Antigone Tsiafitsa, Irini Sotiropoulou, Michalis Tsolakos, Effie Argyri, Mary Nikolaou, Eleni-Anna Vampouli, Christina Filippou, Kyriaki Apergi, Amalia Filippou, Gatsiou Katerina, and Efstratios Dimitriadis; Finnish Institute for Health and Welfare (Finland), Jaana Lindström, Tiina Laatikainen, Katja Wikström, Jemina Kivelä, Päivi Valve, Esko Levälahti, Eeva Virtanen, Tiina Pennanen, Seija Olli, and Karoliina Nelimarkka; Ghent University (Belgium), Department of Movement and Sports Sciences, Greet Cardon, Vicky Van Stappen, and Nele Huys; Department of Public Health, Lieven Annemans and Ruben Willems; Department of Endocrinology and Metabolic Diseases, Samyah Shadid; Technische Universität Dresden (Germany), Peter Schwarz and Patrick Timpel; University of Athens (Greece), Konstantinos Makrilakis, Stavros Liatis, George Dafoulas, Christina-Paulina Lambrinou, and Angeliki Giannopoulou; International Diabetes Federation European Region (Belgium), Winne Ko and Ernest Karuranga; Universidad De Zaragoza (Spain), Luis Moreno, Fernando Civeira, Gloria Bueno, Pilar De Miguel-Etayo, Esther Mª Gonzalez-Gil, María L. Miguel-Berges, Natalia Giménez- Legarre; Paloma Flores-Barrantes, Aleli M. Ayala-Marín, Miguel Seral- Cortés, Lucia Baila-Rueda, Ana Cenarro, Estíbaliz Jarauta, and Rocío Mateo-Gallego; Medical University of Varna (Bulgaria), Violeta Iotova, Tsvetalina Tankova, Natalia Usheva, Kaloyan Tsochev, Nevena Chakarova, Sonya Galcheva, Rumyana Dimova, Yana Bocheva, Zhaneta Radkova, Vanya Marinova, Yuliya Bazdarska, and Tanya Stefanova; University of Debrecen (Hungary), Imre Rurik, Timea Ungvari, Zoltán Jancsó, Anna Nánási, László Kolozsvári, Csilla Semánova, Éva Bíró, Emese Antal, and Sándorné Radó; Extensive Life Oy (Finland), Remberto Martinez and Marcos Tong. We have received permission from those named in the acknowledgement. Author’s Contribution statement: AMK was responsible for conceptualization and literature research, data collection, data curation, formal analysis, validation, visualization, writing – original draft and writing – review & editing. KK was responsible for conceptualization and literature research, data collection, data curation, validation, visualization, writing – original draft and writing – review & editing. CA was responsible for conceptualization and literature research, data collection, data curation, validation, visualization, writing – original draft and writing – review & editing. GC was responsible for methodology, project administration, resources, software, supervision writing – review & editing. ΜDCwas responsible for investigation, validation, supervision writing – review & editing. JK was responsible for methodology, project administration, resources, software, supervision writing – review & editing. VI was responsible for methodology, project administration, resources, software, supervision writing – review & editing. TT was responsible for methodology, project administration, resources, software, supervision writing – review & editing. IR was responsible for methodology, project administration, resources, software, supervision writing – review & editing. SL was responsible for validation, resources, software, supervision writing – review & editing.KM was responsible for validation, resources, software, supervision writing – review & editing. LAM was responsible for methodology, project administration, resources, software, supervision writing – review & editing. YM was responsible for investigation, methodology, project administration, funding acquisition resources, software, supervision writing – review & editing. All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved and all authors have read and agreed to the published version of the manuscript. Conflicts of Interest Disclosure: There are no competing interests. The authors declare no competing interests. Data Availability Statement: The datasets generated and/ or analyzed during the current study are not publicly available, since the data used is confidential based on Feel4Diabetes publication rules, but are available from the corresponding author on reasonable request. References Okunogbe A, Nugent R, Spencer G, Ralston J, Wilding J. Economic impacts of overweight and obesity: current and future estimates for eight countries. BMJ Glob Health. 2021; doi: 10.1136/bmjgh-2021-006351. Weng SF, Redsell SA, Swift JA, Yang M, Glazebrook CP. Systematic review and meta-analyses of risk factors for childhood overweight identifiable during infancy. Arch Dis Child. 2012; doi: 10.1136/archdischild-2012-302263. Dello Russo M, Ahrens W, De Vriendt T, Marild S, Molnar D, Moreno LA et al; IDEFICS Consortium. Gestational weight gain and adiposity, fat distribution, metabolic profile, and blood pressure in offspring: the IDEFICS project. Int J Obes (Lond). 2013; doi: 10.1038/ijo.2013.35. 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Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organ Tech Rep Ser. 2000; PMID: 11234459. Institute of Medicine (US) and National Research Council (US) Committee to Reexamine IOM Pregnancy Weight Guidelines. Weight Gain During Pregnancy: Reexamining the Guidelines. Rasmussen KM, Yaktine AL, editors. Washington (DC): National Academies Press (US); 2009. PMID: 20669500. Villar J, Cheikh Ismail L, Victora CG, Ohuma EO, Bertino E, Altman DG, et al; International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st). International standards for newborn weight, length, and head circumference by gestational age and sex: the Newborn Cross-Sectional Study of the INTERGROWTH-21st Project. Lancet. 2014; doi: 10.1016/S0140-6736(14)60932-6. Kramer MS, Platt RW, Wen SW, Joseph KS, Allen A, Abrahamowicz M, et al; Fetal/Infant Health Study Group of the Canadian Perinatal Surveillance System. 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Obesity (Silver Spring). 2008; doi: 10.1038/oby.2007.35. Monasta L, Batty GD, Cattaneo A, Lutje V, Ronfani L, Van Lenthe FJ, Brug J. Early-life determinants of overweight and obesity: a review of systematic reviews. Obes Rev. 2010; doi: 10.1111/j.1467-789X.2010.00735.x. Koletzko B, Brands B, Demmelmair H; Early Nutrition Programming Project. The Early Nutrition Programming Project (EARNEST): 5 y of successful multidisciplinary collaborative research. Am J Clin Nutr. 2011; doi: 10.3945/ajcn.110.000471. Vehapoglu A, Yazıcı M, Demir AD, Turkmen S, Nursoy M, Ozkaya E. Early infant feeding practice and childhood obesity: the relation of breast-feeding and timing of solid food introduction with childhood obesity. J Pediatr Endocrinol Metab. 2014; doi: 10.1515/jpem-2014-0138. Thompson AL. Evaluating the pathways linking complementary feeding practices to obesity in early life. Nutr Rev. 2020; doi: 10.1093/nutrit/nuz057. Yu Z, Han S, Zhu J, Sun X, Ji C, Guo X. 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Body composition at birth and its relationship with neonatal anthropometric ratios: the newborn body composition study of the INTERGROWTH-21 st project. Pediatr Res. 2017; doi: 10.1038/pr.2017.52. Ali O, Cerjak D, Kent JW, James R, Blangero J, Zhang Y. Obesity, central adiposity and cardiometabolic risk factors in children and adolescents: a family-based study. Pediatr Obes. 2014; doi: 10.1111/j.2047-6310.2014.218.x. Yu ZB, Han SP, Zhu GZ, Zhu C, Wang XJ, Cao XG, et al. Birth weight and subsequent risk of obesity: a systematic review and meta-analysis. Obes Rev. 2011; doi: 10.1111/j.1467-789X.2011.00867.x. Fuemmeler BF, Wang L, Iversen ES, Maguire R, Murphy SK, Hoyo C. Association between Prepregnancy Body Mass Index and Gestational Weight Gain with Size, Tempo, and Velocity of Infant Growth: Analysis of the Newborn Epigenetic Study Cohort. Child Obes. 2016; doi: 10.1089/chi.2015.0253. Baird J, Fisher D, Lucas P, Kleijnen J, Roberts H, Law C. Being big or growing fast: systematic review of size and growth in infancy and later obesity. BMJ. 2005; doi: 10.1136/bmj.38586.411273.E0. Druet C, Stettler N, Sharp S, Simmons RK, Cooper C, Smith GD, et al. Prediction of childhood obesity by infancy weight gain: an individual-level meta-analysis. Paediatr Perinat Epidemiol. 2012; doi: 10.1111/j.1365-3016.2011.01213.x. . Geserick M, Vogel M, Gausche R, Lipek T, Spielau U, Keller E, et al. Acceleration of BMI in Early Childhood and Risk of Sustained Obesity. N Engl J Med. 2018; doi: 10.1056/NEJMoa1803527. Simmonds M, Llewellyn A, Owen CG, Woolacott N. Predicting adult obesity from childhood obesity: a systematic review and meta-analysis. Obes Rev. 2016; doi: 10.1111/obr.12334. Zambrano E, Ibáñez C, Martínez-Samayoa PM, Lomas-Soria C, Durand-Carbajal M, Rodríguez-González GL. Maternal Obesity: Lifelong Metabolic Outcomes for Offspring from Poor Developmental Trajectories During the Perinatal Period. Arch Med Res. 2016; doi: 10.1016/j.arcmed.2016.01.004. Manios Y, Moschonis G, Grammatikaki E, Anastasiadou A, Liarigkovinos T. Determinants of childhood obesity and association with maternal perceptions of their children's weight status: the "GENESIS" study. J Am Diet Assoc. 2010; doi: 10.1016/j.jada.2010.07.004. Tables Table 1 Descriptive data of children and their mothers (%) of Total sample (Ν=12211) Gender Boy 49.4 Girl 50.6 Age 4-7 years 12.7 7-9 years 64.6 9-12 years 22.6 Region High-income countries 26.9 Under economic crisis countries 32.5 Low-income countries 40.6 Children’s weight status Underweight/Normal weight 74.5 Overweight 18.0 Obese 7.5 Maternal age at birth (years) 25-30 34.0 30 50.0 Maternal pre-pregnancy weight status Underweight/ Normal weight 82.2 Overweight 13.7 Obese 4.1 Maternal educational level (years) ≤ 14 years 37.5 > 14 years 62.4 Gestational weight gain Within IOM recommendations 33.1 Below IOM recommendations 33.9 Above IOM recommendations 33.0 Gestational age Full-term (≥ 37 weeks) 79.4 Pre-term (< 37 weeks) 20.6 Maternal smoking during pregnancy No smoking 87.6 Smoking at any trimester 12.4 Maternal diabetes No 94.9 Before pregnancy 0.5 Gestational diabetes 4.6 Infant weight gain in the first 6 months (WHZ) Normal 45.0 Poor (0,67 SD) 39.2 Birth weight for gestational age AGA 72.3 SGA 6.5 LGA 21.2 Breastfeeding Exclusive 26.3 Non-exclusive 59.6 Never 14.1 Timing of solid food introduction 6 months 28.4 IOM, Institute of Medicine report 2009; WHZ, weight-for-height z-score; SD, standard deviation; AGA, appropriate for gestational age(10th–89th percentile); SGA, small for gestational age (90th percentile). Table 2 . Associations between perinatal factors and prevalence of overweight/obesity in children (n= 2663) Independent variables Univariate analysis OR (95%CIs) Multivariate analysis OR (95%CIs) Perinatal characteristics Maternal educational level (years) ≤ 14 years 1.00 1.00 > 14 years 0.82 (0.72-0.91) * 0.74 (0.61-0.89)* Maternal age at birth (years) 25-30 1.00 1.00 30 1.01 (0.91-1.11) 1.15 (0.93-1.42) Maternal pre-pregnancy weight status Underweight/Normal weight 1.00 1.00 Overweight 1.94 (1.65-2.29) ** 1.54 (1.19-1.99) ** Obese 3.27 (2.51-4.26) ** 2.51 (1.57-4.00) ** Maternal diabetes No 1.00 1.00 Before pregnancy 1.46 (0.67-3.22) 4.92 (1.31-18.38) * Gestational diabetes 1.46 (1.13-1.90) * 1.48 (0.97-2.24) Maternal smoking during pregnancy No smoking 1.00 1.00 Smoking at any trimester 1.41 (1.19-1.68) * 1.59 (1.20-2.10) * Gestational weight gain Within IOM recommendations 1.00 1.00 Below IOM recommendations 1.00 (0.85-1.18) 1.09 (0.85-1.40) Above IOM recommendations 1.90 (1.64-2.21) * 2.00 (2.59-2.53) ** Gestational age Full-term (≥37 weeks) 1.00 1.00 Pre-term (<37 weeks) 1.24 (1.06-1.45) 1.23 (0.94-1.60) Birth weight for gestational age AGA 1.00 1.00 SGA 0.70 (0.51-0.97) * 0.57 (0.36-0.89) * LGA 1.40 (1.19-1.64) * 1.49 (1.15-1.92) * Infant weight gain in the first 6 months (WHZ) Normal 1.00 1.00 Poor (0,67 SD) 1.61 (1.36-1.91) * 1.30 (1.04-1.63) * Breastfeeding Exclusive 1.00 1.00 Non-exclusive 1.14 (0.99-1.32) 1.26 (0.99-1.61) Never 1.11 (0.91-1.36) 1.01 (0.71-1.44) Introduction of solids 4-6 months 1.00 1.00 6 months 1.09 (0.95-1.25) 1.17 (0.92-1.47) OR, odds ratio; CI, confidence interval; IOM, Institute of Medicine report 2009; WHZ, weight-for-height z-score; SD, standard deviation; AGA, appropriate for gestational age (10th–89th percentile); SGA, small for gestational age (90th percentile).Statistically significant odds ratios are highlighted in bold:*(P < 0.05), **P<0.01. Multivariate model: Included all perinatal factors found to be associated with overweight/obesity in children at univariate analysis and adjusted for maternal education, child’s sex and age as well as for all the other perinatal factors that were not found to be significantly associated in the univariate analysis. Table 3 Association between sociodemographic factors (maternal education) and children’s overweight/ obesity and the potential mediating effect of perinatal factors a SE b SE c path SE c’ path SE 95% CI Mediated effect Mediator: Maternal pre-pregnancy weight status Maternal education (1:≤14y of education; 2:>14y of education) -0.23* 0.052 0.16* 0.012 - 0. 036* 0.009 -0.14* 0.034 -0.107;-0.046 16.6% Mediator: Gestational weight gain Maternal education -0.05 * 0.011 0.3 0* 0.054 -0.016* 0.004 -0.14* 0.034 -0.027;-0.008 7.76% Mediator: Infant weight gain in the first 6 months (WHZ) Maternal education -0.21 * 0.027 0.08 * 0.027 -0.018* 0.007 -0.14* 0.034 -0.034;-0.004 8.42% Mediator: Birth weight for gestational age Maternal education 0.003 0.015 0.34* 0.042 -0.001* 0.005 -0.14* 0.034 -0.010;0.012 SE, standard error; WHZ, weight-for-height z-score Adjusted for child’s sex and age Values highlighted in bold indicate significance. *(P < 0.05), **P<0.01. 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12:01:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6226046/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6226046/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79663466,"identity":"36382aaf-7541-4e73-b619-466dcf9bc375","added_by":"auto","created_at":"2025-04-01 09:54:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":80293,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMediation model examined in the present study (maternal education [independent variable], children’s perinatal factors [mediator], children’s overweight/ obesity [dependent variable]). Feel4Diabetes study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMediation model depicting the relationship between maternal education (independent variable) and childhood overweight/obesity (dependent variable), with perinatal factors acting as mediators. This model illustrates the pathways through which early-life factors influence obesity risk in children. WHZ, weight to height z-score\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6226046/v1/b288c2d786696176c1dd5ffd.png"},{"id":79665875,"identity":"e6916e68-e497-4aed-9988-d70fad5f0061","added_by":"auto","created_at":"2025-04-01 10:10:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1644312,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6226046/v1/78790497-e215-4b67-9362-f30887a0cd1c.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose","formattedTitle":"Perinatal maternal and child growth mediate the association between maternal education and children’s overweight/obesity in Europe: The Feel4Diabetes-study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eChildhood obesity, a precursor of adult obesity, often begins in the pre-pregnancy or pregnancy period and remains a significant public health challenge.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e In 2022, 37\u0026nbsp;million children under 5 years of age and over 390\u0026nbsp;million aged 5\u0026ndash;19 years were classified as overweight, while 160\u0026nbsp;million lived with obesity. Once predominantly observed in high-income countries, childhood obesity is now increasing in low- and middle-income nations.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Previous studies underscore its multifactorial origins, with numerous risk factors, often starting in the perinatal period, contributing to its development.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePerinatal factors, which influence infants during the intrauterine period and infancy, can induce lasting physiological changes known as metabolic programming, affecting weight status both in early childhood and later in life. The developmental origins of health and disease hypothesis suggests that certain environmental exposures during fetal and early life periods can have long-term implications for health and disease risk.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Early-life interventions and prenatal care are needed to promote long-term health and disease prevention.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e However, perinatal factors are also shaped by sociodemographic factors, with maternal pre-pregnancy obesity, excessive gestational weight gain, smoking during pregnancy, rapid infant weight gain and early solid food introduction being affected by factors such as maternal education, family economic status and ethnicity.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eResearch on the interplay between perinatal factors, sociodemographic influences, and childhood overweight/obesity in Europe remains limited, with most studies focusing on single countries. Few studies have examined how perinatal factors mediate the relationship between sociodemographic determinants and children's weight. Maternal education, a key sociodemographic factor, is a significant predictor of childhood obesity, shaping health behaviors and environmental influences.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Higher maternal education is associated with lower risk of childhood obesity potentially due to positive parenting practices, improved home/environmental management, and reduced exposure to socio-economic disadvantages.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Conversely, lower maternal education is associated with higher rates of smoking during pregnancy, limited breastfeeding, food insecurity and stress related to family dynamics and financial instability.\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Nevertheless, most evidence comes from individual countries (Western and Northern Europe), limiting broader applicability.\u003csup\u003e\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Recognizing this gap, our study investigates these associations across six European countries, considering socioeconomic status(SES), culture, health behaviors, physical activity, and perceptions of healthy weight, to assess whether perinatal factors mediate the maternal education\u0026ndash;childhood obesity link.\u003c/p\u003e"},{"header":"MATERIALS/SUBJECTS \u0026 METHODS","content":"\u003cp\u003e\u003cstrong\u003eStudy design and sampling procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe current study considered the baseline data of the Feel4Diabetes-study (National Clinical Trial number, NCT:02393872) which included a large school and community-based intervention. The Feel4Diabetes study, which had a cluster-randomized design, aimed to promote a healthy lifestyle among school children and their parents including healthy eating and enhancing physical activity. It intended to alleviate the negative outcomes of obesity and obesity-related metabolic risk factors in low socioeconomic status (SES) families in Europe.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe recruitment of this study targeted families from “vulnerable” social groups across six European countries. “Vulnerable” groups were defined as those from low-/middle- income countries (Bulgaria, Hungary), low socio-economic areas in high-income countries (Belgium, Finland) and countries under austerity measures (Greece, Spain). In Bulgaria and Hungary, all areas within the selected provinces were considered “vulnerable” and eligible to participate in the study. In Greece, Spain, Finland and Belgium, the municipalities/school districts/other equivalent units in the selected provinces were grouped in tertiles according to socio-economic indices retrieved from official resources and authorities (e.g. in Greece information was retrieved from the Hellenic Statistical Authority) with “vulnerable” areas randomly selected only from the tertile with the lowest education level or the highest unemployment rate. After approval was obtained from the local authorities (Ethics Committees, Ministries, Municipalities, etc.) lists of schools in these vulnerable areas were created, and primary schools were randomly selected to meet recruitment goals. This sample included children from the first three grades of compulsory education.\u003csup\u003e10\u003c/sup\u003e\u0026nbsp;\u003cbr\u003eWe focused on low SES areas, where children face a significantly elevated obesity risk compared with their wealthier counterparts.\u003csup\u003e11\u003c/sup\u003e Emerging research indicates that the SES–childhood obesity link is intensifying, with an increasing disparity in obesity rates between low- and high-SES groups.\u003csup\u003e11,12\u003c/sup\u003e In many developed countries, childhood obesity rates have stabilized or declined among higher SES groups, whereas they have risen among lower-SES groups.\u003csup\u003e13-15\u003c/sup\u003e These trends underscore the need for targeted interventions in low-SES communities.\u003c/p\u003e\n\u003cp\u003eThe study was designed in 2015, with recruitment starting in January 2016. The initial measurements took place between April and June whereas in Finland, Hungary and Bulgaria they occurred between August and September 2016.\u003csup\u003e10\u003c/sup\u003e The total sample included 12211 children from six European countries, with 2663 having complete data for analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approvals and consent forms\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Feel4Diabetes study adheres to the Helsinki Declaration and the Council of Europe conventions on human rights and biomedicine. Ethical approval was obtained from relevant ethics committees and local authorities in all participating countries. Parents/guardians provided written informed consent before participation. Further details on the approvals are available elsewhere.\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e0\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMEASUREMENTS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnthropometrics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTrained research assistants conducted all the anthropometric measurements via standardized procedures and calibrated portable equipment.\u003csup\u003e16\u003c/sup\u003e Body weight was measured to the nearest 0.1kg via electronic scales (SECA 813), with children in light clothing and without shoes. Height was measured to the nearest 0.1cm using a portable stadiometer (SECA 217), with the children barefoot, and positioned according to the Frankfurt horizontal plane. Measurements were taken twice by dyads of researchers. A third measurement was taken if discrepancies exceeded 100g for weight or 1cm for height. Body Mass Index (BMI) was calculated as weight(kg) divided by height squared(m\u003csup\u003e2\u003c/sup\u003e), with obesity defined using sex- and age-specific BMI cutoffs of the International Obesity Task Force.\u003csup\u003e17\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerinatal data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA structured questionnaire was developed to collect children’s perinatal data from parents via schools, based on established links with childhood obesity in existing literature. It included information from children’s medical records (e.g., children’s body weight and length at birth and six months)\u003csup\u003e2,18-20\u0026nbsp;\u003c/sup\u003eand information regarding (a) maternal age at birth, stratified into \u0026lt;25, 25–30, and \u0026gt;30 years; (b) maternal pre-pregnancy BMI, calculated based on the mother’s self-reported weight pre-pregnancy and current height (categorized as underweight, normal-weight, overweight, or obesity according to the World Health Organization cutoffs)\u003csup\u003e21\u003c/sup\u003e; (c) self-reported gestational weight gain, categorized as less, within, or above the weight gain recommended by the Institute of Medicine\u003csup\u003e22\u003c/sup\u003e; (d) maternal smoking during pregnancy categorized as smoking during any trimester or non-smoking throughout pregnancy; (e) maternal diabetes during pregnancy, categorized as mothers with pre-existing or gestational diabetes and those with a normal glycemic profile; (f) birthweight and gestational age that were used to classify infants as small for gestational age (SGA\u0026lt;10th percentile), appropriate for gestational age (AGA, 10–89th percentile), or large for gestational age (LGA≥90th percentile)\u003csup\u003e23,24\u003c/sup\u003e; (g) children’s growth from birth to six months, based on weight-for-length z-scores (Δ z-score) used to classify growth velocity as slow (Δ z-score\u0026lt;0.67), gradual/normal (Δ z-score=−0.67 to +0.67), or rapid (Δ z-score\u0026gt;0.67).\u003csup\u003e25,26\u003c/sup\u003e Regarding growth assessment, although the change in weight-for-age was used in existing tools, we assessed the change in weight-for-length in our analysis, since it was more strongly associated with the outcome, as also reported elsewhere\u003csup\u003e27\u003c/sup\u003e; (h) breast feeding: exclusive or non-exclusive during the first six months and never breastfed; and (i) time of introduction of solids, categorized as before 4 months, at 4–6 months, or after 6 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSociodemographic data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStandardized self-reported questionnaires were used for all study participants aiming to gather information on basic sociodemographic characteristics (date of birth, ethnicity, maternal education level).\u003csup\u003e28\u003c/sup\u003e Maternal education that was dichotomized into ≤14 and \u0026gt;14 years, considering that \u0026gt;14 years suggests attendance of higher education (e.g., bachelor’s program).\u0026nbsp;This questionnaire\u0026nbsp;was also developed and administered to parents via schools.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eContinuous variables are presented as means ± standard deviations and categorical values as proportions (%). The normality of distribution of variables was determined by the Kolmogorov–Smirnov test and histograms. Univariate logistic regression was used to analyze the associations between perinatal factors (independent variables) and childhood overweight/obesity (dependent variable). Significant factors were further assessed via multivariable logistic regression, adjusting for child age, sex, maternal education, and non-significant perinatal factors from the univariate logistic regression. The mediation analysis tested whether perinatal factors mediated the link between maternal education and childhood overweight/obesity, using one exposure variable (i.e., maternal education) and children’s overweight/obesity as the main outcome. Statistical analysis was performed via STATA statistics/Data Analysis, (College Station,Texas,USA) version 15.1. Level of statistical significance was set at p \u0026lt; 0.05.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe analysis included data from 2,663 children aged 4-12 years, with 49.4% of whom were boys. Among the participants, 40.6% were from low-income countries, 32.5% were from countries under economic crisis, and 26.9% were from high-income countries. Overall, 18% were children with overweight and 7.5% with obesity. Study and perinatal characteristics are detailed in Tables 1 and 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUnivariate analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 presents the univariate analysis results, showing significant associations between maternal pre-pregnancy factors and childhood overweight/obesity. Maternal overweight (OR 1.94 (95%CI 1.65–2.29)) and obesity (OR 3.27 (95%CI 2.51–4.26)) increased the odds of childhood overweight/obesity compared with maternal underweight/normal weight. Excessive gestational weight gain (OR 1.90 (95%CI 1.64–2.21)) also increased the odds compared with appropriate gestational weight gain. Children born SGA (OR 0.70 (95%CI 0.51–0.97)) had lower odds, whereas those born LGA (OR 1.40 (95%CI 1.19–1.64)) and those with rapid weight gain during the first 6 months (evaluated with the weight-for-height z-score (WHZ)) had higher odds (OR 1.61 (95%CI 1.36–1.91)) of overweight/obesity. No associations were found for breastfeeding and time of solid food introduction.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMultivariate analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 displays the multivariable analysis results for the variables identified as significantly associated with children's overweight/obesity in the univariate analysis, adjusted for maternal education, sex, and age. Maternal overweight (OR 1.54 (95%CI 1.19–1.99)) obesity (OR 2.51 (95%CI 1.57–4.00)), pre-pregnancy diabetes (OR 4.92 (95%CI 1.31–18.38)), smoking in pregnancy (OR 1.59 (95%CI 1.20–2.10)) and excessive gestational weight gain (OR 2.00 (95%CI 2.59–2.53)) remained significantly associated with childhood overweight/obesity. Children born SGA had lower odds (OR 0.57 (95%CI 0.36–0.89)), whereas those born LGA had higher odds (OR 1.49 (95%CI 1.15–1.92)) of childhood overweight/obesity than those born appropriate for gestational age. Rapid weight gain during the first 6 months remained positively associated (OR 1.30 (95%CI 1.04–1.63)) with \u0026nbsp;childhood overweight/obesity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMediation analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mediation model examined in the current study is presented in Figure 1. Table 4 shows the results derived from the mediation analysis. Maternal education was significantly associated with maternal pre-pregnancy weight status, infant weight gain in the first six months (WHZ) and gestational weight gain in \u003cstrong\u003epath a\u003c/strong\u003e, whereas in \u003cstrong\u003epath b\u003c/strong\u003e, overweight/obesity was associated with maternal pre-pregnancy weight status, gestational weight gain, infant weight gain in the first six months (WHZ) and birthweight. Finally, maternal education was significantly associated with children’s overweight/obesity (OR -0.21 (95%CI -0.28 to -0.14)) (\u003cstrong\u003epath c\u003c/strong\u003e). \u003cstrong\u003ePath c’\u003c/strong\u003e which represents the direct effect of maternal education on children’s overweight/obesity was statistically significant (p=0.0001), indicating that there is partial mediation by perinatal factors. The proportion mediated by maternal pre-pregnancy weight status in the association between maternal education and children’s overweight/obesity was 16.6%, that for gestational weight gain was 7.8% and that for rapid weight gain in the first six months (WHZ) was 8.4%, whereas birthweight for gestational age did not have a significant mediating effect.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe present study examined the associations among perinatal factors and childhood overweight/obesity. Given that maternal education is a strong sociodemographic predictor of childhood overweight/obesity\u003csup\u003e32\u003c/sup\u003e this study also explored the mediating role of perinatal factors in this association.\u003c/p\u003e \u003cp\u003eOur findings indicated that maternal pre-pregnancy overweight/obesity, pre-pregnancy diabetes, smoking during pregnancy, excessive gestational weight gain, high birthweight for gestational age and rapid weight gain in the first 6 months were significantly associated with increased odds of childhood overweight/obesity. Conversely, low birthweight for gestational age was linked to lower odds.\u003c/p\u003e \u003cp\u003eThese findings align with previous research supporting the relationship between perinatal factors and childhood overweight/obesity.\u003csup\u003e2,29,30\u003c/sup\u003e However, there was no significant association between breastfeeding and timing of solid food introduction with overweight/obesity, which is consistent with prior studies. The inconsistency in these associations may stem from variations in study endpoints (e.g., exclusive vs. mixed breastfeeding, milk substitutes, timing of solid food introduction), age ranges, methodologies, and sample sizes.\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMaternal characteristics, particularly elevated pre-pregnancy BMI and excessive gestational weight gain have been strongly linked to childhood obesity. A meta-analysis of 45 studies revealed that maternal pre-pregnancy overweight/obesity doubled the odds of childhood overweight and tripled obesity odds from infancy to adolescence.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Another meta-analysis reported that infants born to mothers with overweight/obesity presented greater fat mass and body fat percentage than those born to mothers with normal BMI.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e Compared with women with obesity, women with normal weight or overweight may be more susceptible to the effects of excessive weight gain during pregnancy.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Weight gain during early and mid-pregnancy, which primarily reflects increased maternal fat rather than fetal weight, may contribute to greater adiposity in offspring due to increased maternal fuel availability.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e According to the IOM guidelines, excessive gestational weight gain is a recognized risk factor for childhood overweight/obesity.\u003csup\u003e36\u003c/sup\u003e A systematic review and meta-analysis further confirmed that excessive gestational weight gain increases the likehood of childhood obesity.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePrevious studies have primarily focused on gestational diabetes mellitus, leaving the association between pre-gestational diabetes and childhood obesity less well understood. Research on maternal pre-pregnancy diabetes has largely focused on its links to congenital malformations, perinatal mortality and morbidity, with limited attention given to long-term childhood outcomes. One prior study examined the associations between maternal diabetes, LGA status and overweight/obesity in preschool-aged children. They revealed that the LGA risk alone (39.4%) was more than twice that of gestational diabetes alone (16.0%) or pre-existing diabetes alone (15.1%). Notably, the risk of childhood obesity was highest in LGA children born to mothers with gestational or pre-existing type 2 diabetes.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e Our study further established a clear association between maternal pre-existing diabetes and childhood overweight/obesity, independent of other risk factors.\u003c/p\u003e \u003cp\u003eAdditionally, maternal smoking during pregnancy increased the odds of childhood overweight/obesity, a finding supported by substantial evidence. A recent meta-analysis confirmed that maternal smoking during pregnancy increased the risk of overweight/obesity in offspring.\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e Moreover, maternal smoking has a greater impact than paternal smoking, suggesting that maternal smoking has a more pronounced intrauterine effect than does paternal or household smoking.\u003c/p\u003e \u003cp\u003eFurthermore, high birthweight for gestational age was associated with higher childhood overweight/obesity odds, whereas low birthweight was protective. Although high birthweight is a known risk factor, few studies have reported a positive link between low birthweight and obesity. Generally, SGA is defined as a birthweight below the 10th percentile and LGA as a birthweight above the 90th percentile\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e; however these definitions can vary.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e Such definitions are somewhat arbitrary, as both low and high birthweight are associated with future health risks.\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e A J- or U-shaped association suggests that both extremes may increase childhood obesity risk.\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMost studies investigating obesity risk rely on weight or BMI, which might not precisely capture disparities in body composition. Limited research has examined how weight variations are distributed between fat and fat-free mass. Differences in adiposity at birth may indicate metabolic dysfunction, highlighting the importance of measuring body fat. Visceral adiposity is associated with increased cardiometabolic risk.\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e Studies employing more precise techniques like dual-energy X-ray absorptiometry and magnetic resonance imaging have produced mixed findings.\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e However, the inclusion criteria and varying birthweight cutoff points make it difficult to draw firm conclusions. A meta-​analysis that is in line with our results, reported that birthweight\u0026thinsp;\u0026gt;\u0026thinsp;4,000g increases the risk of later obesity, whereas low (\u0026lt;\u0026thinsp;2,500g) and normal range (2,500-4,000g) birthweight were not related to obesity risk.\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn this study, rapid weight gain in the first six months of life was associated with higher odds of childhood overweight/obesity. In healthy infants, weight typically decreases during the first two weeks, then increases relative to height, peaking around 6 weeks, before gradually stabilizing by six months.\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e Deviations from this growth pattern are linked to future obesity risk and adult health.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e,\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e Infants with an earlier growth peak or fasted weight gain during the first two years are more susceptible to obesity and chronic diseases later in life.\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e Numerous studies\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e including a meta-analysis found that each 1-SD increase in weight from birth to one year doubles the risk of childhood obesity\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e underscoring the long-term impact of early weight gain.\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e,\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMediation analysis revealed that less educated mothers are at greater risk of having children with overweight/obesity and this association is partially mediated by maternal pre-pregnancy overweight/obesity, increased gestational weight gain and rapid infant weight gain. A lower education level contributes to maternal overweight/obesity, leading to LGA infants and creating an obesogenic environment, that promotes an increase in childhood BMI.\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e Additionally, women with lower education levels may face barriers to healthcare access, leading to inadequate monitoring of gestational weight gain and potentially suboptimal outcomes.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e Conversely, women with higher education typically have better access to prenatal care, monitor weight gain during pregnancy and are more informed about healthy lifestyle, which may positively influence children's nutritional and feeding behaviors.\u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e This knowledge could translate into better feeding practices, with a diverse and nutrient-rich diet. These mothers are less likely to overfeed their infants, thus preventing rapid growth velocity\u0026mdash;a well-documented early risk factor for childhood obesity and related comorbidities.\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e,\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e,\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAn important strength of this study is its large sample with data from over 12211 participants across six European countries and specifically from families of low SES regions that have been previously underexplored. Lower SES is associated with unhealthy maternal behaviors including smoking, alcohol consumption, and limited prenatal care, all of which increase the risk of complications during pregnancy and childbirth. Additionally, socioeconomic disparities can affect access to nutritious food and overall dietary quality. The standardized protocols and procedures across all centers, along with objective anthropometric measurements, ensure reliable and generalizable findings. On the other hand, some of the collected data were self-reported. Although the validity and reliability of the relevant questionnaires were tested before the intervention started, this approach is prone to recall and social desirability bias. The present study is a cross-sectional secondary analysis of Feel4Diabetes intervention using only data from the baseline, therefore no inferences about causality can be made.\u003c/p\u003e \u003cp\u003eThis study revealed the significant role of perinatal factors and maternal education in childhood overweight/obesity. Specifically, maternal pre-pregnancy overweight/obesity, excessive gestational weight gain, and rapid infant growth partially mediated the inverse association between maternal education and childhood obesity. The urgent need for targeted public health interventions in lower education families is emphasized, with a focus on improving healthcare access, prenatal monitoring, and raising awareness to encourage healthy weight management and lifestyle habits.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e The authors would like to thank the members of the Feel4Diabetes-study group: coordinator, Yannis Manios; steering committee, Yannis Manios, Greet Cardon, Jaana Lindström, Peter Schwarz, Konstantinos Makrilakis, Lieven Annemans, and Winne Ko; Harokopio University (Greece), Yannis Manios, Kalliopi Karatzi, Odysseas Androutsos, George Moschonis, Spyridon Kanellakis, Christina Mavrogianni, Konstantina Tsoutsoulopoulou, Christina Katsarou, Eva Karaglani, Irini Qira, Efstathios Skoufas, Konstantina Maragkopoulou, Antigone Tsiafitsa, Irini Sotiropoulou, Michalis Tsolakos, Effie Argyri, Mary Nikolaou, Eleni-Anna Vampouli, Christina Filippou, Kyriaki Apergi, Amalia Filippou, Gatsiou Katerina, and Efstratios Dimitriadis; Finnish Institute for Health and Welfare (Finland), Jaana Lindström, Tiina Laatikainen, Katja Wikström, Jemina Kivelä, Päivi Valve, Esko Levälahti, Eeva Virtanen, Tiina Pennanen, Seija Olli, and Karoliina Nelimarkka; Ghent University (Belgium), Department of Movement and Sports Sciences, Greet Cardon, Vicky Van Stappen, and Nele Huys; Department of Public Health, Lieven Annemans and Ruben Willems; Department of Endocrinology and Metabolic Diseases, Samyah Shadid; Technische Universität Dresden (Germany), Peter Schwarz and Patrick Timpel; University of Athens (Greece), Konstantinos Makrilakis, Stavros Liatis, George Dafoulas, Christina-Paulina Lambrinou, and Angeliki Giannopoulou; International Diabetes Federation European Region (Belgium), Winne Ko and Ernest Karuranga; Universidad De Zaragoza (Spain), Luis Moreno, Fernando Civeira, Gloria Bueno, Pilar De Miguel-Etayo, Esther Mª Gonzalez-Gil, María L. Miguel-Berges, Natalia Giménez- Legarre; Paloma Flores-Barrantes, Aleli M. Ayala-Marín, Miguel Seral- Cortés, Lucia Baila-Rueda, Ana Cenarro, Estíbaliz Jarauta, and Rocío Mateo-Gallego; Medical University of Varna (Bulgaria), Violeta Iotova, Tsvetalina Tankova, Natalia Usheva, Kaloyan Tsochev, Nevena Chakarova, Sonya Galcheva, Rumyana Dimova, Yana Bocheva, Zhaneta Radkova, Vanya Marinova, Yuliya Bazdarska, and Tanya Stefanova; University of Debrecen (Hungary), Imre Rurik, Timea Ungvari, Zoltán Jancsó, Anna Nánási, László Kolozsvári, Csilla Semánova, Éva Bíró, Emese Antal, and Sándorné Radó; Extensive Life Oy (Finland), Remberto Martinez and Marcos Tong. \u003cstrong\u003eWe have received permission from those named in the acknowledgement.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor’s Contribution statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAMK was responsible for conceptualization and literature research, data collection, data curation, formal analysis, validation, visualization, writing – original draft and writing – review \u0026amp; editing. \u0026nbsp;KK was responsible for conceptualization and literature research, data collection, data curation, validation, visualization, writing – original draft and writing – review \u0026amp; editing. \u0026nbsp;CA was responsible for conceptualization and literature research, data collection, data curation, validation, visualization, writing – original draft and writing – review \u0026amp; editing. \u0026nbsp;GC was responsible for methodology, project administration, resources, software, supervision writing – review \u0026amp; editing. ΜDCwas responsible for\u0026nbsp;investigation, validation,\u0026nbsp;supervision writing – review \u0026amp; editing. JK\u0026nbsp;was responsible for methodology, project administration, resources, software, supervision writing – review \u0026amp; editing. VI was responsible for methodology, project administration, resources, software, supervision writing – review \u0026amp; editing.\u0026nbsp;TT\u0026nbsp;was responsible for methodology, project administration, resources, software, supervision writing – review \u0026amp; editing.\u0026nbsp;IR\u0026nbsp;was responsible for methodology, project administration, resources, software, supervision writing – review \u0026amp; editing.\u0026nbsp;SL\u0026nbsp;was responsible for validation, resources, software, supervision writing – review \u0026amp; editing.KM\u0026nbsp;was responsible for validation, resources, software, supervision writing – review \u0026amp; editing.\u0026nbsp;LAM was responsible for methodology, project administration, resources, software, supervision writing – review \u0026amp; editing.\u0026nbsp;YM\u0026nbsp;was responsible for investigation,\u0026nbsp;methodology, project administration, funding acquisition resources, software, supervision writing – review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eAll authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved and all authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest Disclosure:\u0026nbsp;\u003c/strong\u003eThere are no competing interests. The authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e The datasets generated and/ or analyzed during the current study are not publicly available, since the data used is confidential based on Feel4Diabetes publication rules, but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eOkunogbe A, Nugent R, Spencer G, Ralston J, Wilding J. Economic impacts of overweight and obesity: current and future estimates for eight countries. BMJ Glob Health. 2021; doi: 10.1136/bmjgh-2021-006351.\u003c/li\u003e\n \u003cli\u003eWeng SF, Redsell SA, Swift JA, Yang M, Glazebrook CP. Systematic review and meta-analyses of risk factors for childhood overweight identifiable during infancy. 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Adv Nutr. 2012; doi: 10.3945/an.111.001081.\u003c/li\u003e\n \u003cli\u003eAyine P, Selvaraju V, Venkatapoorna CMK, Geetha T. Parental Feeding Practices in Relation to Maternal Education and Childhood Obesity. Nutrients. 2020; doi: 10.3390/nu12041033.\u003c/li\u003e\n \u003cli\u003eWhite PA, Awad YA, Gauvin L Spencer NJ, McGrath JJ, Clifford SA, et al; EPOCH Collaborative Group. Household income and maternal education in early childhood and risk of overweight and obesity in late childhood: Findings from seven birth cohort studies in six high-income countries. Int J Obes (Lond). 2022; doi: 10.1038/s41366-022-01171-7.\u003c/li\u003e\n \u003cli\u003eDixon B, Pe\u0026ntilde;a MM, Taveras EM. Lifecourse approach to racial/ethnic disparities in childhood obesity. Adv Nutr. 2012; doi: 10.3945/an.111.000919.\u003c/li\u003e\n \u003cli\u003eManios Y, Androutsos O, Lambrinou CP, Cardon G, Lindstrom J, Annemans L, et al. 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J Pediatr Endocrinol Metab. 2014; doi: 10.1515/jpem-2014-0138.\u003c/li\u003e\n \u003cli\u003eThompson AL. Evaluating the pathways linking complementary feeding practices to obesity in early life. Nutr Rev. 2020; doi: 10.1093/nutrit/nuz057.\u003c/li\u003e\n \u003cli\u003eYu Z, Han S, Zhu J, Sun X, Ji C, Guo X. Pre-pregnancy body mass index in relation to infant birth weight and offspring overweight/obesity: a systematic review and meta-analysis. PLoS One. 2013; doi: 10.1371/journal.pone.0061627.\u003c/li\u003e\n \u003cli\u003eCastillo-Laura H, Santos IS, Quadros LC, Matijasevich A. Maternal obesity and offspring body composition by indirect methods: a systematic review and meta-analysis. Cad Saude Publica. 2015; doi: 10.1590/0102-311X00159914.\u003c/li\u003e\n \u003cli\u003eStarling AP, Brinton JT, Glueck DH, Shapiro AL, Harrod CS, Lynch AM, et al. Associations of maternal BMI and gestational weight gain with neonatal adiposity in the Healthy Start study. Am J Clin Nutr. 2015; doi: 10.3945/ajcn.114.094946.\u003c/li\u003e\n \u003cli\u003eRasmussen KM, Catalano PM, Yaktine AL. New guidelines for weight gain during pregnancy: what obstetrician/gynecologists should know. Curr Opin Obstet Gynecol. 2009; doi: 10.1097/GCO.0b013e328332d24e.\u003c/li\u003e\n \u003cli\u003eMamun AA, Mannan M, Doi SA. Gestational weight gain in relation to offspring obesity over the life course: a systematic review and bias-adjusted meta-analysis. Obes Rev. 2014; doi: 10.1111/obr.12132.\u003c/li\u003e\n \u003cli\u003eKaul P, Bowker SL, Savu A, Yeung RO, Donovan LE, Ryan EA. Association between maternal diabetes, being large for gestational age and breast-feeding on being overweight or obese in childhood. Diabetologia. 2019; doi: 10.1007/s00125-018-4758-0.\u003c/li\u003e\n \u003cli\u003eRiedel C, Sch\u0026ouml;nberger K, Yang S, Koshy G, Chen YC, Gopinath B et al. 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Pediatr Obes. 2014; doi: 10.1111/j.2047-6310.2014.218.x.\u003c/li\u003e\n \u003cli\u003eYu ZB, Han SP, Zhu GZ, Zhu C, Wang XJ, Cao XG, et al. Birth weight and subsequent risk of obesity: a systematic review and meta-analysis. Obes Rev. 2011; doi: 10.1111/j.1467-789X.2011.00867.x.\u003c/li\u003e\n \u003cli\u003eFuemmeler BF, Wang L, Iversen ES, Maguire R, Murphy SK, Hoyo C. Association between Prepregnancy Body Mass Index and Gestational Weight Gain with Size, Tempo, and Velocity of Infant Growth: Analysis of the Newborn Epigenetic Study Cohort. Child Obes. 2016; doi: 10.1089/chi.2015.0253.\u003c/li\u003e\n \u003cli\u003eBaird J, Fisher D, Lucas P, Kleijnen J, Roberts H, Law C. Being big or growing fast: systematic review of size and growth in infancy and later obesity. BMJ. 2005; doi: 10.1136/bmj.38586.411273.E0.\u003c/li\u003e\n \u003cli\u003eDruet C, Stettler N, Sharp S, Simmons RK, Cooper C, Smith GD, et al. Prediction of childhood obesity by infancy weight gain: an individual-level meta-analysis. Paediatr Perinat Epidemiol. 2012; doi: 10.1111/j.1365-3016.2011.01213.x.\u003c/li\u003e\n \u003cli\u003e. Geserick M, Vogel M, Gausche R, Lipek T, Spielau U, Keller E, et al. Acceleration of BMI in Early Childhood and Risk of Sustained Obesity. N Engl J Med. 2018; doi: 10.1056/NEJMoa1803527.\u003c/li\u003e\n \u003cli\u003eSimmonds M, Llewellyn A, Owen CG, Woolacott N. Predicting adult obesity from childhood obesity: a systematic review and meta-analysis. Obes Rev. 2016; doi: 10.1111/obr.12334.\u003c/li\u003e\n \u003cli\u003eZambrano E, Ib\u0026aacute;\u0026ntilde;ez C, Mart\u0026iacute;nez-Samayoa PM, Lomas-Soria C, Durand-Carbajal M, Rodr\u0026iacute;guez-Gonz\u0026aacute;lez GL. Maternal Obesity: Lifelong Metabolic Outcomes for Offspring from Poor Developmental Trajectories During the Perinatal Period. Arch Med Res. 2016; doi: 10.1016/j.arcmed.2016.01.004.\u003c/li\u003e\n \u003cli\u003eManios Y, Moschonis G, Grammatikaki E, Anastasiadou A, Liarigkovinos T. Determinants of childhood obesity and association with maternal perceptions of their children\u0026apos;s weight status: the \u0026quot;GENESIS\u0026quot; study. J Am Diet Assoc. 2010; doi: 10.1016/j.jada.2010.07.004.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"754\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 754px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Descriptive data of children and their mothers\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e(%) of Total sample\u003c/p\u003e\n \u003cp\u003e(\u0026Nu;=12211)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eBoy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e49.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eGirl\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e50.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e4-7 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e7-9 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e64.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e9-12 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e22.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eRegion\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eHigh-income countries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e26.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eUnder economic crisis countries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e32.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eLow-income countries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e40.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChildren\u0026rsquo;s weight status\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eUnderweight/Normal weight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e74.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eOverweight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e18.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eObese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e7.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal age at birth (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e25-30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e34.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026lt; 25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e16.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026gt; 30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal pre-pregnancy weight status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eUnderweight/ Normal weight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e82.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eOverweight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e13.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eObese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal educational level (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026le; 14 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e37.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026gt; 14 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e62.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGestational weight gain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eWithin IOM recommendations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e33.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eBelow IOM recommendations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e33.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eAbove IOM recommendations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e33.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGestational age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eFull-term (\u0026ge; 37 weeks)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e79.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003ePre-term (\u0026lt; 37 weeks)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e20.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal smoking during pregnancy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eNo smoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e87.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eSmoking at any trimester\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e12.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal diabetes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e94.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eBefore pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eGestational diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInfant weight gain in the first 6 months (WHZ)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e45.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003ePoor (\u0026lt;-0,67 SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e15.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eRapid (\u0026gt;0,67 SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e39.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBirth weight for gestational age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eAGA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e72.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eSGA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e6.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eLGA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e21.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBreastfeeding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eExclusive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e26.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eNon-exclusive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e59.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e14.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 302px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTiming of solid food introduction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026lt; 4 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e9.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e4-6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e62.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 236px;\"\u003e\n \u003cp\u003e\u0026gt; 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e28.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 754px;\"\u003e\n \u003cp\u003eIOM, Institute of Medicine report 2009; WHZ, \u0026nbsp;weight-for-height z-score; SD, standard deviation; AGA, appropriate for gestational age(10th\u0026ndash;89th percentile); SGA, small for gestational age (\u0026lt;10th percentile); LGA, large for gestational age (\u0026gt;90th percentile).\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\" width=\"945\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 945px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAssociations between perinatal factors and prevalence of overweight/obesity in children (n= 2663)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIndependent variables\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnivariate analysis\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95%CIs)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMultivariate analysis\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eOR (95%CIs)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerinatal characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal educational level (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003e\u0026le; 14 years\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003e\u0026gt; 14 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.82 (0.72-0.91)\u003c/strong\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.74 (0.61-0.89)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal age at birth (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003e25-30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003e\u0026lt;25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.22 (1.08-1.39)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.01 (0.72-1.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003e\u0026gt;30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.01 (0.91-1.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.15 (0.93-1.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal pre-pregnancy weight status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eUnderweight/Normal weight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eOverweight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.94 (1.65-2.29)\u003c/strong\u003e\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.54 (1.19-1.99)\u003c/strong\u003e\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eObese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.27 (2.51-4.26)\u003c/strong\u003e\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.51 (1.57-4.00)\u003c/strong\u003e\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal diabetes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eBefore pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.46 (0.67-3.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e4.92 (1.31-18.38)\u003c/strong\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eGestational diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.46 (1.13-1.90)\u003c/strong\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.48 (0.97-2.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal smoking during pregnancy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eNo smoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eSmoking at any trimester\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.41 (1.19-1.68)\u003c/strong\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.59 (1.20-2.10)\u003c/strong\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGestational weight gain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eWithin IOM recommendations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eBelow IOM recommendations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.00 (0.85-1.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.09 (0.85-1.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eAbove IOM recommendations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.90 (1.64-2.21)\u003c/strong\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.00 (2.59-2.53)\u003c/strong\u003e\u003cstrong\u003e**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGestational age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eFull-term (\u0026ge;37 weeks)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003ePre-term (\u0026lt;37 weeks)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.24 (1.06-1.45)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.23 (0.94-1.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBirth weight for gestational age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eAGA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eSGA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.70 (0.51-0.97)\u003c/strong\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.57 (0.36-0.89)\u003c/strong\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eLGA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.40 (1.19-1.64)\u003c/strong\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.49 (1.15-1.92)\u003c/strong\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInfant weight gain in the first 6 months (WHZ)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003ePoor (\u0026lt;-0,67 SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.02 (0.80-1.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.01 (0.74-1.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eRapid (\u0026gt;0,67 SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.61 (1.36-1.91)\u003c/strong\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.30 (1.04-1.63)\u003c/strong\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBreastfeeding\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eExclusive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eNon-exclusive\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.14 (0.99-1.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.26 (0.99-1.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003eNever\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.11 (0.91-1.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.01 (0.71-1.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 307px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntroduction of solids\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003e4-6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003e\u0026lt; 4 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e0.82 (0.65-1.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e0.90 (0.62-1.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003e\u0026gt; 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e1.09 (0.95-1.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 215px;\"\u003e\n \u003cp\u003e1.17 (0.92-1.47)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 945px;\"\u003e\n \u003cp\u003eOR, odds ratio; CI, confidence interval; IOM, Institute of Medicine report 2009; WHZ, \u0026nbsp; \u0026nbsp; weight-for-height z-score; SD, standard deviation; AGA, appropriate for gestational age (10th\u0026ndash;89th percentile); SGA, small for gestational age (\u0026lt;10th percentile); LGA, large for gestational age (\u0026gt;90th percentile).Statistically significant odds ratios are highlighted in bold:*(P \u0026lt; 0.05), **P\u0026lt;0.01. Multivariate model: Included all perinatal factors found to be associated with overweight/obesity in children at univariate analysis and adjusted for maternal education, child\u0026rsquo;s sex and age as well as for all the other perinatal factors that were not found to be significantly associated in the univariate analysis.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"973\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\" valign=\"top\" style=\"width: 973px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e Association between sociodemographic factors (maternal education) and children\u0026rsquo;s overweight/ obesity and the potential mediating effect of \u0026nbsp; \u0026nbsp; perinatal factors\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 19px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ea\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eb\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ec path\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;c\u0026rsquo; path\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMediated effect\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\" valign=\"top\" style=\"width: 973px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMediator:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal pre-pregnancy weight status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal education\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(1:\u0026le;14y of education;\u003c/p\u003e\n \u003cp\u003e2:\u0026gt;14y of education)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.23*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.052\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.16*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.012\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003cstrong\u003e0.\u003c/strong\u003e\u003cstrong\u003e036*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.009\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.14*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.034\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.107;-0.046\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e16.6%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\" valign=\"top\" style=\"width: 973px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMediator:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eGestational weight gain \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.05\u003c/strong\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.011\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.3\u003c/strong\u003e\u003cstrong\u003e0*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.054\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.016*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.004\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.14*\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.034\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.027;-0.008\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7.76%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\" valign=\"top\" style=\"width: 973px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMediator:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eInfant weight gain in the first 6 months (WHZ)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.21\u003c/strong\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.027\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.08\u003c/strong\u003e\u003cstrong\u003e*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.027\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.018*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.007\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.14*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.034\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.034;-0.004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e8.42%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\" valign=\"top\" style=\"width: 973px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMediator:\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBirth weight for gestational age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 131px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaternal education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 63px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.34*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.042\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.005\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-0.14*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.034\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e-0.010;0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 95px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"12\" valign=\"top\" style=\"width: 973px;\"\u003e\n \u003cp\u003eSE, standard error; WHZ, \u0026nbsp; \u0026nbsp; weight-for-height z-score\u003c/p\u003e\n \u003cp\u003eAdjusted for child\u0026rsquo;s sex and age\u003c/p\u003e\n \u003cp\u003eValues highlighted in bold indicate significance. *(P \u0026lt; 0.05), **P\u0026lt;0.01.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-obesity","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"ijo","sideBox":"Learn more about [International Journal of Obesity](http://www.nature.com/ijo/)","snPcode":"41366","submissionUrl":"https://mts-ijo.nature.com/cgi-bin/main.plex","title":"International Journal of Obesity","twitterHandle":"@intjobesity","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Obesity, childhood, perinatal, pregnancy, education","lastPublishedDoi":"10.21203/rs.3.rs-6226046/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6226046/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground/Objectives:\u003c/strong\u003e Early-life factors and maternal education interact with childhood overweight/obesity through pathways that remain unclear. Our aim was to investigate the predominant perinatal correlates of childhood overweight/obesity and their mediating effects on the association between maternal education and children's overweight/obesity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubjects/Methods:\u003c/strong\u003e In this cross-sectional study the total sample included 12211 children (4–12 years-old) from low socioeconomic status (SES) regions in six European countries, with 2663 having complete data for analysis.\u003c/p\u003e\n\u003cp\u003eInterventions/methods: All measurements were carried out during August-September 2016. Children’s anthropometrics were measured and parents self-reported all other data (perinatal/ sociodemographic) via questionnaires. All variables were adjusted for maternal education, sex and age (p\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Maternal overweight (OR 1.54 (95% CI 1.19–1.99)), obesity (OR 2.51 (95% CI 1.57–4.00)), pre-pregnancy diabetes (OR 4.92 (95% CI 1.31–18.38)), smoking during pregnancy (OR 1.59 (95% CI 1.20–2.10)) and excessive gestational weight gain (OR 2.00 (95% CI 2.59–2.53)) were associated with childhood overweight/obesity. Children born small-for-gestational-age (OR 0.57 (95% CI 0.36–0.89)) had lower odds, whereas those born long-for-gestational-age (OR 1.49 (95% CI 1.15–1.92)) had higher odds of childhood overweight/obesity. Rapid weight gain during the first 6 months was positively associated (OR 1.30 (95% CI 1.04–1.63)) with overweight/obesity in children. Maternal pre-pregnancy weight status, rapid weight gain in the first 6 months and gestational weight gain mediated by 16.6%, 8.4%, and 7.8%, respectively, the maternal education-child obesity link.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003ePerinatal factors play a crucial role in the onset of childhood obesity, and evidence suggests their association with maternal education. Families with lower education should be targeted, aiming to raise awareness of health issues related to maternal/children’s healthy lifestyle and improve nutrition knowledge, aiming to ensure healthy maternal weight prior to and during pregnancy and normal infant growth.\u003c/p\u003e","manuscriptTitle":"Perinatal maternal and child growth mediate the association between maternal education and children’s overweight/obesity in Europe: The Feel4Diabetes-study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-01 09:54:30","doi":"10.21203/rs.3.rs-6226046/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2025-10-14T11:02:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-10-08T05:51:18+00:00","index":4,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-09-22T07:08:08+00:00","index":4,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-08-01T14:48:32+00:00","index":3,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-07-27T06:40:31+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-07-16T10:33:50+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-04-11T12:47:15+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2025-03-22T07:40:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-17T13:10:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Obesity","date":"2025-03-14T11:56:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-14T11:56:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-obesity","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"ijo","sideBox":"Learn more about [International Journal of Obesity](http://www.nature.com/ijo/)","snPcode":"41366","submissionUrl":"https://mts-ijo.nature.com/cgi-bin/main.plex","title":"International Journal of Obesity","twitterHandle":"@intjobesity","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"8e445081-4fc9-4f4a-99c7-b5e517cc922a","owner":[],"postedDate":"April 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":46056331,"name":"Health sciences/Health care/Paediatrics"},{"id":46056332,"name":"Health sciences/Health care/Public health/Epidemiology"}],"tags":[],"updatedAt":"2026-03-30T11:34:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-01 09:54:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6226046","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6226046","identity":"rs-6226046","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}