Discuss the steps required to submit research to a professional journal, and what you feel will be the biggest obstacle. Why?

Reply to each part with 1-2 paragraphs well developed, inculding references.

Part 1 – Discuss the steps required to submit research to a professional journal, and what you feel will be the biggest obstacle. Why?

https://online.vitalsource.com/reader/books/978128…

Part 2 – Read the article on the impact of maternal prenatal smoking on the development of childhood overweight in school-aged children from the WCU library. Is the article quantitative, qualitative, or something else? State the study design, research question, and the strength and limitations of the study. Can the study results be generalized? Why or why not?

Requirements: 1-2 paragraphs

Theimpactofmaternalprenatalsmokingonthedevelopmentofchildhoodoverweightinschool-agedchildrenL.Wang1,H.M.Mamudu2andT.Wu1,31DepartmentofBiostatisticsandEpidemiology,CollegeofPublicHealth,EastTennesseeStateUniversity,JohnsonCity,TN,USA;2DepartmentofHealthServicesManagementandPolicy,CollegeofPublicHealth,EastTennesseeStateUniversity,JohnsonCity,TN,USA;3DepartmentofFamilyMedicine,JamesH.QuillenCollegeofMedicine,EastTennesseeStateUniversity,JohnsonCity,TN,USAReceived6March2012;revised10July2012;accepted24August2012Whatisalreadyknownaboutthissubject•Maternalsmokingduringpregnancylikelyincreasetheriskofchildhoodoverweight.•Childhoodoverweightisinfluencedbysocioeconomiccharacteristicsofmothers.•Characteristicsofchildatbirthdeterminethelikelihoodofoverweight.Whatthisstudyadds•Childrenofmotherswhosmoked1yearbeforebirth(includingpregnancy)werelikelytobeoverweightduringschoolagesthanthoseofmotherswhoneversmoked.•Confirmationthatsocioeconomiccharacteristicsofmothersinfluencethelikelihoodofchildhoodoverweightduringschoolage.•Smokingcessationshouldbetargetedatmothers1yearbeforebirthtoimprovetheirhealthstatusandthatofoffspring.SummaryObjectives:Toexamineassociationsbetweenmaternalsmokingandoverweightamongschool-agedchildrenandalsoidentifymothersandoffspringcharacteristicsthataffectchildren’sweight.Methods:WeuseddatafromtheNationalInstituteofChildHealthandHumanDevelopment(NICHD)StudyofEarlyChildCareandYouthDevelopment(SECCY).ChildhoodoverweightwasdefinedashavingBodyMassIndex(BMI)of85thpercentileorabove.Smokingpatternsamongmotherswereassessedbyquestioningsmokingbehaviour1yearbeforebirthofthetargetchild:neveroreversmoking.Standardizedprocedureswereusedtomeasureheightandweight.Descriptivestatisticsandgeneralizedestimatingequations(GEE)wereusedfortheanalysis.Results:Descriptiveresultsshowedthatchildrenofmotherswhosmokedanytimewithin1yearbeforebirthweremorelikelytobeoverweightandhavehigherBMIpercentileaverages.GEEresultsshowedthatchildrenofmotherswhowereeversmokers1yearbeforebirthweremorelikelytobeoverweight(OR=1.39,95%CI:1.01,1.94)andhavehigherBMIpercentileaverages(b=4.46,P=0.036)fromgrades1through6thanthoseofmotherswhowereneversmokers.Additionally,thelevelofmother’seducationandbirthweightweresignificantlyassociatedwithchildhoodoverweight.Conclusions:Confirmedrelationshipsbetweenmaternalsmokingandoverweightamongschool-agedchildrenhaveimportantimplicationsforpublichealthpolicybecausethisevidencecanbeusedtoenhancesmokingcessation1yearbeforebirthtoimprovethehealthstatusofmothersandoffspring.Keywords:Childhoodoverweight,longitudinalstudy,maternalprenatalsmoking,riskfactor.Addressforcorrespondence:DrLWang,DepartmentofBiostatisticsandEpidemiology,EastTennesseeStateUniversity,POBox70259,JohnsonCity,TN37614,USA.E-mail:[email protected]©2012TheAuthorsPediatricObesity©2012InternationalAssociationfortheStudyofObesity.PediatricObesity8,178–188PEDIATRICOBESITY ORIGINALRESEARCHdoi:10.1111/j.2047-6310.2012.00103.xORIGINALRESEARCH

IntroductionTheprevalenceofoverweightandobesityhasbeenincreasingworldwideandhasemergedasaglobalpublichealthissue(1),thusleadingtoeffortstoiden-tifytherootcausesoftheproblem.DatafromtheNationalHealthandNutritionExaminationSurvey(NHANES)intheUnitedStatesindicatethattheprevalenceofadultoverweightandobesitywas34.4%in2008(2)and35.7%in2010(3).Thedataalsoshowthattheprevalenceofoverweightandobesityamongschool-agedchildrenbetween6and11yearsofagein2008was35.5%and19.6%,respectively(4).Therateofprevalenceofobesityinchildrenbetween2and19yearsofage(16.9%)remainedsteadybetween2008and2010despiteeffortstoreduceit(5).Forthisreason,theobesityrate31%in2010intheUnitedStatesisexpectedtoreachover42%by2030ifdrasticeffortsarenottakentoidentifythesourcesandinterventionsforit(6).OverweightandobesityamongchildrenintheUnitedStateshasincreaseddramaticallyoverthepastthreedecadestoreachepidemicproportions.Obesityinchildrenagedtwoyearsandolderhasatleastdoubledinthelast25yearsandtripledinthepast30years(7).Thedramaticincreaseinchildhoodoverweightandobesityhasresultedin‘childhood’diseasesthatwereoncethoughtofasprimarily‘adult’diseases,suchastypeIIdiabetes(8),hyper-tension,hyperlipidemia,highcholesterollevelsandabnormalglucosetolerance(9,10).Additionally,over-weightchildrenandadolescentsoftenhavepsycho-socialproblems,includingcompromisedhealthrelatedtoqualityofphysical,emotionalandsocialwell-being(11–14).Moreover,obesechildrenareleastdesiredtobefriendedbypeers(15)andmorelikelytobebullied(16),whichleadstoapoorself-imagethatpersistsintoadulthood(17).Thus,over-weightorobesityisnotonlyahealthproblembutalsoasocialproblem.However,theageatwhichoverweightandobesitystartsisnotobvious,thusdemandinginvestigationintothesourcesoftheproblemforearlyintervention.Previousstudieshaveidentifiedsocioeconomic,demographicandenvironmentaldeterminantsofoverweightandobesity(1,18).Increasingstudiesonpopulationsinplaces,suchasJapan(19),Europe(20),Canada(21)andtheUnitedStates(22)haveturnedtothelifestyleofmothersthatimpactfoetalprogrammingandleadtooverweightorobesityinchildhood(andadulthood).Akeymarkerforchild-hood(andadult)obesityismaternalsmoking(1,23–26).Thisrelationshipisduetoanumberofpossiblereasons,includingintrauterinemalnutrition(27)andtoxiceffectsofcigarettesmoke(28)thatmayresultinelevatedconcentrationofcortisolinthecordblood(29).Allthesemetabolicmechanismsmayhaveanadverseimpactonfoetalprogrammingandcouldnegativelyimpacttheweightofoffspring(30).Thus,maternalsmokingdoesnotonlyleadtolowbirthweight(31),butitisalsorelatedtocatchingupgrowthinchildhoodthatleadstooverweightandobesity(32,33).Despitethisincreasingevidence,studiesabouttheeffectsofwhetherornotthemotherhadeversmokedwithintheentireyearbeforebirthontheweightstatusofoffspringaresparse.Therefore,thisstudyanalyzeseffectsofmothers’smokingstatuswithin1yearbeforebirthonoverweightofschool-agedchildrenintheUnitedStatesusinglongitudinalcohortdata.Simultane-ously,thestudyidentifiesmaternalandoffspringcharacteristicsthatimpacttheweightofoffspringduringschoolages.Whilethestudyhelpstoidentifymothers’behavioursthatimpacttheweightofoffspring,itprovidesusefulinformationforunder-standingfoetalprogrammingandsuggeststhattheyearbeforethebirthmaybeanimportantperiodforinterventiontopreventchildhoodoverweight.Thisstudymaycontributetotargetingmaternalsmokingbehaviourbeforebirthanditsadverseoutcomeasanintegralpartofeffortstopreventtheobesityrateinthecountryfromreaching42%by2030(6).MaterialsandmethodsDatasourceandparticipantsSince1991,theNationalInstituteofChildHealthandHumanDevelopment(NICHD)StudyofEarlyChildCareandYouthDevelopment(SECCYD)hasbeenconductedat10researchhospitalsacrosstheUnitedStates.Detailedrecruitmentandselectionprocedureshavebeenpublishedinapreviousstudy(34)andhttp://www.nichd.nih.gov/research/supported/seccyd/overview.cfm.Inbrief,ofatotalof8986mothersthatgavebirthintheresearchhospitalsduringsamplingperiodsin1991,5416(60%)agreedtobetelephonedin2weeks.Theexclusioncriteriaformother–babydyadsincludedmothersyoungerthan18years,thosethatdidnotspeakEnglish,didnotagreewiththe2-weekphonecall,hadhistoryofsubstanceabuseandthebabyhadmedicalcomplications.Additionalexclu-sioncriteriawereneighbourhoodsunsafeforteamsofresearcherstovisit,familieslivinginthesamelocationforlessthan1yearandfamilieslivingtoofarawayfromtheresearchsite(morethan1hdrive)(35).ThesecriteriawereusedtoscreenoutverylowMaternalsmokingandchildhoodoverweight|179ORIGINALRESEARCH©2012TheAuthorsPediatricObesity©2012InternationalAssociationfortheStudyofObesity.PediatricObesity8,178–188

birthweight,prematureorsickinfants.Guidedbythemothers’planstoreturntoworkorschoolwithinayearafterdelivery(intheratioof3:1:1–full-timeworkers:part-timeworkers:non-workers),thecon-ditionallyrandomsampling,asketch-basedsam-plingtechnique,thatincludestheadvantagesofbothsketchingandrandomsampling(36)wasdesignedtoprovidesufficientdatatoallowforsomestatisticaladjustmentstoreflectcharacteristicsofthebasesample.Thesamplingtechniquewasusedtoensurethatsingle-parent,low-maternaleducationandminoritydistributionaltargetsweremetwhilecon-tinuingtoselectcasesatrandom(37).DatafromtheHospitalRecruitmentandGestationalAgeformswereenteredintoadatabaseattheDataCoordinat-ingCenter(DCC).ConditionalrandomcallinglistswerethengeneratedbytheDCC.Asampleof3015(56%)motherswasselectedfromthe5416motherswhoagreedtobetelephonedin2weeks.Ofthese3015mothersinthesample,1526wereavailablefortheinterviewat1monthageofthechild.Ofthe1526mothers,1364(89.4%)finishedtheinterviewandbecamestudyparticipantsin1991.At24monthsinterviewafterbirth,twopeople,avisitcoordinator/examinerandcameraoperator,conductedthelabo-ratoryvisit.Thevisitcoordinator/examinerwasresponsibleforgreetingthefamily,explainingeachproceduretothemotherandadministeringthepro-cedures;andtheoperatorservedasoperatorofthevideocamera.Motherswereaskedtorecalltheirprenatalsmokinghabits.Inthisstudy,werestrictedchildrenwithmeasureofbodymassindex(BMI)atoneormoretimepoints(grades1,3or6)andthosewhosemotherswerenotmissinginformationontheirsmokingbehaviourswithin1yearbeforebirthtogetouranalyticsample(1041).PhaseI(1991–1994),phaseII(1995–2000)andphaseIII(2000–2005)oftheSECCYDdatawereusedintheanalysis.Theattritionrateforthestudysamplewas20.1%.TheInstitutionalReviewBoardofEastTennesseeStateUniversityapprovedthisstudy.VariablesChildhoodoverweightstatusThekeyoutcomevariablewasBMIpercentile,whichwascalculatedaccordingtotheU.S.CentersforDiseaseControlandPrevention’s(CDC)ageandgender-specificgrowthcharts(38).TheCDC’snomenclaturedefinedoverweightforachildasaBMI(definedasweightinkilogramsdividedbysquaredheightinmeters)equaltoorgreaterthanthe85thpercentile.Assuch,theoutcomevariableinthisstudy,childhoodoverweightstatus,wasmeasuredasadichotomizedvariable(BMI85thpercentileornormalweight,BMI85thpercentileorover-weight).StandardizedprocedureswereusedtomeasureheightandweightduringtheinterviewsbyNICHDSECCYstaff.Heightwasmeasuredwithchil-drenstandingwithoutshoes,feettogetherandtheirbacksagainstacalibrated7-footmeasuringstick.Weightwasmeasuredusingaphysician’s2-beamscale.Scaleswerecalibratedmonthlyusingcertifiedcalibrationweights.Weightwasmeasuredwithchil-dreninminimalclothingandrecordedtwice,eachtimetothenearest0.25pound(0.1kg).ThisNICHDSECCYstudyfollowedthesamechildrenfrombirththroughgrades1(2000),3(2002)and6(2005).WeuseddataonBMIvaluesfromwhenthechildrenwereinthesegradesasoutcomevariables.MaternalprenatalsmokingMother’ssmokingstatuswithin1yearbeforethebirth(1990)ofthetargetchildwereassessedretro-spectivelywith‘Theyearbeforemychildwasborn’question(39),whichconsistedoftwoitemsmeasur-ingmother’ssmokingbehaviourshortlybeforeandduringpregnancy.Becauseofthesmallsamplesize(1041)andstudypurposes,mother’ssmokingstatuswasdividedintotwocategories,neversmokingandeversmokingwithin1yearbeforethebirthoftargetchild.CovariatesThemaincovariates,whichencompassedmaternalcharacteristics,werecollectedatthe1monthofchildageinterview.Thesecovariatesincludemater-nalage,education(bachelor’sdegreeorabove,lessthanabachelor’sdegree),livingstatus(livingsingle,notlivingsingle),poverty(abovepovertyline,i.e.$6932forasinglepersonand$8797forafamilyoftwoin1991(40),atorbelowpovertyline)andbreast-feedingstatus(breastfeeding,notbreastfeeding).Othercovariatesinvolvedoffspringcharacteristics,suchassex,ethnicityandbirthweight.Childsexandethnicitywererecordedat1monthafterbirth.Thesamplesizesforindividualethnicminoritygroupswerenotlargeenoughtoallowseparatesubgroups’analyses,thus,thisstudycategorizedethnicityintoWhites,Blacks,orOthers.Child’sbirthweightingramswasobtainedfrommedicalchartasacon-tinuousvariable.StatisticalanalysisWeanalyzedthesedatausingunivariate(frequen-ciesandpercentages),bivariate(chi-squareand180|L.Wangetal.ORIGINALRESEARCH©2012TheAuthorsPediatricObesity©2012InternationalAssociationfortheStudyofObesity.PediatricObesity8,178–188

t-test)andmultivariate(GeneralizedEstimatingEquations[GEE])statistics.Inthebivariateanalysis,whilethechi-squaretestwasusedtodeterminewhetherthereisanyassociationbetweencategori-calvariables,thestudentt-testwasusedtodeter-minewhetherthereisanydifferenceinthemeansofcontinuousvariablesbetweentwogroups.Usingchi-squaretestandstudentt-test,wecomparedmaternalandchild’scharacteristicsinouranalyticsample(n=1041)withthoseexcludedduetoincompletedataonchildhoodoverweightinschoolagesandmaternalsmokingstatuswithin1yearbeforethebirth(n=323).Wethencomparedmater-nalandchild’scharacteristicswithdichotomousmaternalsmokingstatus(neversmokervs.eversmoker)within1yearbeforethebirthinouranalyticsample.Additionally,todescribethedistributionofoverweightstatusinthetwogroupsatthreemeas-ures,weexaminedthedistributionofmeanBMIper-centilesandproportionsofoverweightchildrenbymaternalsmokingstatus(neversmokervs.eversmoker)within1yearbeforethebirthatgrades1,3and6,respectively.Finally,weusedGEEforthemultivariateanalysisbecause,incomparisonwithtraditionalregressionanalysisatonetimepoint(cross-sectional),itconsidersallrepeatedmeasure-mentsofthehealthoutcomesbyaccountingfortheirdependency(41,42).Morespecifically,classicalanalysessuchasregressiondonotconsiderthepatternacrosstime,andarenotadequatetoaddresschangesinmeanresponseovertime.Inthislongitudinalstudy,theindependenceassumptionwasnotsatisfiedbecausechildrenweremeasuredatmultiplefollow-uptimepoints.Forthisreason,thecorrelationofdatawithineachchildcouldbecloseandshouldnotbeignored.TheGEEwasusedtoaddressthisissuethroughtheuseof‘workingcor-relation’structuretoaccountforthewithin-subjectcorrelationofresponseondependentvariablesofdifferentdistributions(41).Inotherwords,GEEmodelswereusedtoaccountforwithin-subjectcorrelationacrossthreetimepoints(grades1,3and6)ofmeasurementsforcategorical(childhoodoverweightstatus)andcontinuous(BMIpercentile)variables.While74.4%ofchildrenhadBMImeas-urementsatallthreetimepoints,89.4%hadBMImeasurementsatleastattwotimepoints.Inthislongitudinalstudy,themissingBMIpercentileswereassumedtobemissingatrandom,whichwasregu-larlyusedtoaddressmissingdatainlongitudinaldataanalysis(43).First-orderauto-regression[AR(1)]wasusedastheworkingcorrelationmatrixforper-formingtheGEEtoaccountforcorrelationsamongrepeatedmeasurementsintheBMI.Statisticalsig-nificancewasdefinedashavingaP-value0.05fortwo-tailedtesting.AlldataanalyseswereperformedusingPASWversion18.0statisticalsoftware(IBMSPSS,Chicago,Illinois).ResultsOfthe1041mothers,812(78%)wereneversmokersand229(22%)wereeversmokers.Thecharacteris-ticsofthestudysamplewereshowninTable1.Themeanageofthemotherswasabout29years,andthemajorityofthemhadlessthanabachelor’sdegree(60.6%),werenotlivingsingle(87.2%),wereabovethepovertyline(82.1%;$6932forasingleand$8865forafamilyoftwoin1991(37))andwerebreastfeed-ing(62%).Withrespecttotheoffspring,halfofthemweremales(50.4%),moreoftenwhite(81.5%)andhadameanbirthweightof3503.2grams.Comparedwithmothersintheanalyticsample(n=1041),mothersintheexcludedsampleduetoincompletedata(n=323)weremorelikelytosmokewithin1yearbeforebirth(P=0.002),haveyoungerages(P<0.0001),havelowereducation(P<0.0001),livingsingle(P=0.001),atorbelowpovertyline(P<0.0001)andbreastfeed(P<0.0001).Withrespecttochild’ssex,ethnicityandbirthweight,therewerenodifferencebetweenanalyticandexcludedsamples.Table2showsthatcomparedtoneversmokers,eversmokersweremorelikelytobeseeninmotherswhohadyoungerage(P<0.0001),werelessedu-catedthanbachelor’sdegree(P<0.0001),livingsingle(P<0.0001),atorbelowpovertylevel(P=0.001)andnotbreastfeeding(P<0.0001).ThedistributionofmeanBMIpercentileandpro-portionsofoverweightchildrendescribedbymater-nalsmokingstatuswithin1yearbeforethebirthandatthetimeofassessmentwerereportedinTable3.Generally,theproportionofchildhoodoverweight(25.0%,31.2%and33.7%atgrades1,3and6,respectively)andmeanBMIpercentileincreasedwithincreasesinthelevelofschoolgrade,suggestingapositiverelationshipbetweengradelevelandweight.Additionally,childrenofmotherswhowereeversmokersweremorelikelytobeoverweightthanthoseofmotherswhodidnotsmoke(30.3%vs.23.5%,37.1%vs.29.6%,41.4%vs.31.6%atgrades1,3and6,respectively),andonaverage,havehigherBMIpercentiles.GEEresultsafteradjustingforthecovariateswerereportedinTable4,whichshowedthatmaternalsmokingwithin1yearbeforebirthwassignificantlyassociatedwithchildhoodoverweight.Thatis,chil-drenofmotherswhowereeversmokersweremoreMaternalsmokingandchildhoodoverweight|181ORIGINALRESEARCH©2012TheAuthorsPediatricObesity©2012InternationalAssociationfortheStudyofObesity.PediatricObesity8,178–188

likelytobeoverweight(OR=1.39,95%CI:1.01,1.94)andhavehigherBMIpercentile(b=4.46,P=0.036)fromgrades1through6thanchildrenofmotherswhowereneversmokersduringtheyearbeforethebirth.Additionally,twocovariates,mater-naleducationandbirthweightofoffspringweresig-nificantlyassociatedwithchildhoodoverweight.Inthisrespect,childrenofmotherswithlessthanabachelordegreeweremorelikelytobeoverweight(OR=1.41,95%CI:1.05,1.91)andchildrenwithhigherbirthweight(inkilograms)werealsolikelytobeoverweight(OR=1.99,95%CI:1.52,2.61).Allothercovariateswerenotsignificant.DiscussionTobaccouseduringpregnancyisamajorpublichealthissueduetothenegativeeffectsonboththemotherandoffspring(4).Whilematernalprenatalsmokingisknowntobelinkedwithnegativehealtheffectsonoffspring,suchaslowbirthweight(31),evidenceofitseffectsontheweightofoffspringisstillsparse.Ourstudyinvestigatedeffectsofwhetherthemotherhadeversmokedwithin1yearbeforethebirthofthetargetchildontheweightofthechildduringschoolages.Consistentwiththeexistinglit-eraturethatlinkedsmokingduringpregnancywithTable1ComparisonofmaternalandchildcharacteristicsofthestudysampleintheanalyticsamplewiththosenotincludedduetoincompletedataAnalyticsample*Notinanalyticsample†POverall[n(%)]1041(76.3)323(23.7)MaternalcharacteristicsSmokingstatus1yearbeforebirth‡0.002Eversmoker229(22.0)50(33.8)Neversmoker812(78.0)98(66.2)Age§Meanageatdelivery,years(SD)28.6(5.5)26.5(5.7)<0.0001Education‡Bachelor’sdegreeorabove(%)410(39.4)72(22.4)Lessthanabachelor’sdegree(%)631(60.6)250(77.6)Livingstatus‡0.001Livingsingle(%)133(12.8)65(20.2)Notlivingsingle(%)906(87.2)257(79.8)Povertylevel‡<0.0001Atorbelowpovertyline(%)176(17.9)97(33.2)Abovepovertyline(%)805(82.1)195(66.8)Breastfeedingstatus‡<0.0001Notbreastfeeding(%)396(38.0)191(59.1)Breastfeeding(%)645(62.0)132(40.9)OffspringcharacteristicsSex‡0.096Male(%)525(50.4)180(55.7)Female(%)516(49.6)143(44.3)Ethnicity‡0.099Whites(%)848(81.5)249(77.1)Blacks(%)123(11.8)53(16.4)Others(%)70(6.7)21(6.5)Birthweight§Meanbirthweight,grams(SD)3503.2(511.4)3445.5(489.0)0.332*Subjectedincludedinanalyticsample(n=1041).Ofthese,1wasmissingdataonlivingsinglestatus,60weremissingdataonmaternalpovertylevel.†Subjectsexcludedduetoincompletedataonchildhoodoverweightinschoolagesandchildrenwhosemothersweremissinginformationontheirsmokingbehaviourswithin1yearbeforebirth(n=323).Ofthese,2weremissingdataonlivingsinglestatus,31weremissingdataonmaternalpovertylevel,and1wasmissingdataonmaternaleducation.‡Chi-square(c2)testwasusedforP-value.§T-testwasusedforP-value.182|L.Wangetal.ORIGINALRESEARCH©2012TheAuthorsPediatricObesity©2012InternationalAssociationfortheStudyofObesity.PediatricObesity8,178–188

childhoodoverweightandobesity(1,23),ourstudydiscoveredahigherprevalenceofoverweightamongchildrenofmotherswhoeversmokedwithin1yearbeforethebirth.Afteradjustingforcovariates,GEEresultsshowedthatmaternalsmokingwithin1yearbeforebirthsignificantlyincreasedthelikelihoodofoverweightby1.39times,suggestingtheneedforsmokingcessationprogrammestoencouragemotherstoabstainfromsmokingatleastayearbeforethebirthofthetargetchild.Althoughmostofthecovariates(maternalandoff-springcharacteristics)inourstudywerenotsignifi-cantlyassociatedwithchildhoodoverweight,thetwosignificantones,thelevelofeducationandbirthTable2Characteristicsoftheanalyticsamplebymaternalsmokingstatus*within1yearbeforethebirth(n=1041)NeversmokerEversmokerPOverall[n(%)]812(78)229(22)MaternalcharacteristicsAge†<0.0001Meanageatdelivery,years(SD)29.1(5.4)26.8(5.6)Education‡<0.0001Bachelor’sdegreeorabove(%)372(45.8)38(16.6)Lessthanbachelor’sdegree(%)440(50.2)191(83.4)Livingstatus‡<0.0001Livingsingle(%)84(10.4)49(21.4)Notlivingsingle(%)726(89.6)180(78.6)Povertylevel‡0.001Atorbelowpovertyline(%)122(15.8)54(26.1)Abovepovertyline(%)652(84.2)153(73.9)Breastfeedingstatus‡<0.0001Notbreastfeeding(%)282(34.7)114(49.8)Breastfeeding(%)530(65.3)115(50.2)OffspringcharacteristicsSex‡0.60Male(%)406(50.0)119(52.0)Female(%)406(50.0)110(48.0)Ethnicity‡0.28Whites(%)662(81.5)186(81.2)Blacks(%)100(12.3)23(10.0)Others(%)50(6.2)20(8.7)Birthweight†0.01Meanbirthweight,grams(SD)3524.9(516.2)3426.3(487.4)Note:Numberofmissingobservations:single=2;poverty=60.*Motherswereinterviewedatchildren24monthsafterbirthfortheirsmokingstatuswithin1yearbeforethebirth.†ttestwasused,thenumbersindicatemeanstandarddeviation(SD).‡chi-square(c2)testwasused,thenumbersindicatepercentagevalues.Table3DistributionofmeanBMI-P*andproportionsofoverweightchildrenbymaternalprenatalsmokingstatus†andtimeofassessment(n=1041)TimeNeversmokerEversmokerTotalnBMI_P*Overweight‡(%)nBMI_P*Overweight‡(%)nBMI_P*Overweight‡(%)Grade175661.923.520865.630.396462.725.0Grade370663.829.619767.837.190364.731.2Grade669362.331.618669.741.487963.933.7*Astandardizedprotocoltomeasurechild’sweightandheightwasusedatallthreetimes(grades1,3,6).Bodymassindex(BMI)wascalculatedby[BMI=weight(kg)/height(m)2].†Motherswereinterviewedatchildren24monthsafterbirthfortheirsmokingstatuswithin1yearbeforethebirth.‡OverweightwasdefinedasaBMI-for-ageabovethe85thpercentileoftheCentersforDiseaseControlandPreventionsex-specificBMI-for-agegrowthcharts(35).BMI-P,bodymassindexpercentile.Maternalsmokingandchildhoodoverweight|183ORIGINALRESEARCH©2012TheAuthorsPediatricObesity©2012InternationalAssociationfortheStudyofObesity.PediatricObesity8,178–188

weightofoffspring,needattention.Whiletheevi-dencelinkingsocioeconomicstatusofmotherandoverweightorobesityofchildrenisstillnotobvious(21,44),itwasdiscoveredinourstudythatamothernothavingabachelordegreesignificantlyincreasesthelikelihoodofchildhoodoverweightby1.41times.Thisfindingsuggeststhateducation,beingadrivingdeterminantofsocioeconomicstatus,maybeapredictorforincreasedriskofoverweightamongoff-spring,especiallyasmotherswithlowersocioeco-nomicstatustendtosmokemore.Ontheissueofbirthweight,ourfindingisconsistentwiththeextantliteraturethathigherbirthweightisassociatedwithoverweightandobesityinchildhood(45).ThisresultsuggeststheimportanceofattendingtonutritionalneedsofchildrenbornwithhigherBMIs.Lastly,resultsonbreastfeedingareworthyofconsiderationastheevidenceofitseffectsonchildhoodoverweightandobesityisnotconclusive(46,47).Theresultsofourstudysuggestthatbreastfeedingisprobablyaprotectivepracticeforchildhoodoverweight.Ingeneral,thefindingsinourstudyareconsistentwithpreviousepidemiologicalstudiesontheeffectsofmaternalprenatalsmokingontheoverweightstatusofchildren(21)andourcontributiontothisliteraturepertainstotheeffectofmotherssmokingwithin1yearbeforethebirthofthetargetchild.BecauseourstudyassessedmaternalsmokingTable4LongitudinalanalysisofmeanBMI-Pandover-weightstatusfromgrades1through6usingGEE*(n=1041)BMI-P†Overweightstatus‡bSEPOR95%CIPMaternalsmokingstatusdNeversmoker(reference)Eversmoker4.462.120.0361.391.01–1.940.047MaternalcharacteristicsAgeMeanageatdelivery,years-0.220.180.2350.980.96–1.010.189EducationBachelor’sdegreeorabove(reference)Lessthanbachelor’sdegree2.251.950.2491.411.05–1.910.025LivingstatusNotlivingsingle(reference)Livingsingle1.333.460.7010.900.53–1.540.710PovertylevelAbovepovertyline(reference)Atorbelowpovertyline1.882.720.4900.930.62–1.390.72BreastfeedingstatusNotbreastfeeding(reference)Breastfeeding-3.101.850.0930.780.59–1.040.087OffspringcharacteristicsSexFemales(reference)Males-0.411.660.8051.060.82–1.370.672EthnicityWhites(reference)Blacks5.633.020.0621.480.94–2.320.087Others0.083.720.9831.110.67–1.830.699Birthweight(kg)11.351.64<0.00011.991.52–2.61<0.0001*AnalysisoftheGEEparameterestimateswasbasedontheuseoffirstorderauto-regressiveworkingcorrelation[AR(1)]structure,withBMI_Pascontinuousoutcomeandoverweightasdichotomousoutcome,respectively.†Astandardizedprotocoltomeasurechild’sweightandheightwasusedatall3times(grades1,3,6).BMIwascalculatedby[BMI=weight(kg)/height(m)2].‡OverweightwasdefinedasaBMI-for-ageabovethe85thpercentileoftheCentersforDiseaseControlandPreventionsex-specificBMI-for-agegrowthcharts(35).dMotherswereinterviewedatchildren24monthsafterbirthfortheirsmokingstatuswithin1yearbeforethebirth.BMI_P,bodymassindexpercentile;CI,confidenceinterval;GEE,generalizedestimatingequations;OR,oddsratio;SE,standarderror.184|L.Wangetal.ORIGINALRESEARCH©2012TheAuthorsPediatricObesity©2012InternationalAssociationfortheStudyofObesity.PediatricObesity8,178–188

statusfortheentireyearbeforethebirth,includingafewmonthsbeforepregnancyandtheperiodofpregnancy,possibleexplanationsfortheassociationwithnegativeeffectsontheweightofoffspringcanbederivedfromtheextantliterature.First,becausetobaccoisanaddictiveproduct(31),motherswhosmokedafewmonthsbeforepregnancywilllikelycontinuetosmokethroughpregnancy.Inotherwords,thereisthepossibilitythatpregnancywillnotbedeterrencefromsmokingformotherswhosmokedafewmonthsbeforepregnancyastobaccoisanaddictiveproduct.Evenifthemothersquitsmokingduringpregnancy,thepotentialofrecidi-vismishigh,andtheymayrevertbacktosmoking.Second,hypothalamicdysfunctionandabnormalfatcellsthatresultfromsmokingcouldexplaintheposi-tiveassociationbetweenmaternalprenatalsmokingandoverweightandobesityofoffspring(48).Previ-ousstudiesdiscoveredthatmaternalprenatalsmokingincreasednicotinelevels,whichresultedintheirmaternalstarvation(49).Animalstudiessuggestthatmaternalstarvationisassociatedwithobesityinoffspring(50,51)andthatitmightbecausedbyalteredhypothalamicregulatorymechanismsofenergyintakeandexpenditure(52).Third,thecatch-upthesissuggeststhatlowbirthweightduetomaternalprenatalsmokingisassociatedwitharapidcatch-upgrowthphaseinchildrenfrombirthtograde6,whichleadstooverweightandobesity(32,33,53).Simultaneously,somestudieshaveshownthathigherbirthweightisapredictorforincreasedriskofchildhoodobesity(54,55).Fourth,childrenofsmokerstendtobephysicallyinactive,i.e.engageinlessthan60minofphysicalactivityperday(56)andhaveaninadequatehealthydiet,i.e.insufficientfatintakeof25%to35%kcal,carbohy-drateintakeof45%to65%andproteinintakesof10%to30%kcal(57).Theselifestyleissuesleadtooverweightorobesity(58–60).Takingeverythingintoconsideration,bothfoetalgrowthandweightgaininearlyinfancyaredirectlyassociatedwithweightinlaterlife(1,61).Thismeansthatmaternalprenatalsmokinghaslong-termnegativeeffectsonoffspring,demandingstrategictobaccocessationpro-grammesforwomenatleast1yearbeforethebirth.Thisstudyislimitedbythefactthatthereislackofdatafordeterminingtheinfluenceofgeneticfactors,whicharedeterminantsoftheoverweight(62)andshowimportantrolesofmaternalpregravidobesity,paternalandmaternalBMI(63,64),parentalweightstatus(65),maternalweightgainduringpregnancy(66)andchangeinparentalweightafterbirth(24,65)inthedevelopmentofoverweightchildren.Moreover,thedietaryintakeofchildrenwasnotassessed,butpreviousstudiessuggestitisapredictorofchildhoodobesity(67).Further,althoughenvironmentalfactors,includingscreeningtime(TVviewingandcomputeruse)(68)playroleinthelikelihoodofoverweightandobesity(69),wedidnothavethedataforthisanaly-sis.Thus,residualconfoundingremainspossibleduetoexclusionofsomepredictorsthatmaypartlyexplaintheobservedassociations.ThestudyisalsolimitedbythenatureofparticipantsinvolvedintheNICHDSECCYdata.First,theparticipantswerevol-unteers,whichissubjecttoself-selectionbias.Second,socialdesirability,atendencytoexpressfavouriteanswers,maycompromisethevalidityoftheself-reportedquestionnaireofmaternalsmokinghabitrecall.Third,someselectionbiasmayhaveoccurredduetoincompletedatacausedbylosttofollow-upandmissingdata.Inouranalyticsample(1041),motherswerelesslikelytosmokethanexcludedmothers(323),whichimplythatwemaybeunderestimatingtheassociationbetweenmaternalsmokingandtheriskofoverweightofoffspring.Fourth,maternaleducationwasassumedtobethesameasatthe1monthinterview,althoughitcouldhavechangedinthecourseofthestudy.Despitethesedrawbacks,thestudyusedlongitudinal-cohortdatatoprovideepidemiologicalinsightintohowsmokingwithin1yearbeforethebirthhaslong-termnegativeimplicationsfortheweightofchildrenandcouldhelpinfindinginterventionstopreventtheobesityratefromreaching42%oftheU.S.adultpopulationby2030(6).ConclusionsTheconfirmedrelationshipbetweenoverweightandmaternalprenatalsmokinginschool-agedchildrenhasimportantimplicationsforpublichealthpolicyandhealthstatusofindividualmothersandoffspring.Theintegrationoffindingsofthisstudyintobaccousepreventionprogrammeswithin1yearbeforethebirthoftargetchildcouldincreasetherateofcessa-tion,whichwillhelptoimprovethehealthstatusofoffspring.Thus,ourstudysuggeststhattoreducechildhoodoverweightandobesity,smokingcessa-tionshouldstartbeforepregnancy.ConflictsofintereststatementTheauthorshavenonetodeclare.AcknowledgementTheresearchwassupportedbyasmallgrantfromtheResearchDevelopmentCommitteeofEastTen-Maternalsmokingandchildhoodoverweight|185ORIGINALRESEARCH©2012TheAuthorsPediatricObesity©2012InternationalAssociationfortheStudyofObesity.PediatricObesity8,178–188

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