Nayana Dubier Professor Wolcott October 17, 2013

FINAL

A Look into the Connection between Obesity and Gestational Diabetes and the Consequences In the Obstetrician medical field, the number one focus is to ensure that the pregnant women and their babies are in good conditions in order for a healthy delivery. However, sometimes this is difficult due to unplanned complications, etc. One complication that has become more prevalent in the last decade is Gestational Diabetes Mellitus. According to the American Journal of Public Health and the American College of Obstetricians and Gynecologists, Gestational Diabetes Mellitus (GDM) is defined as carbohydrate intolerance leading to hyperglycemia with onset or first recognition during pregnancy(Shin et al e65). Medical researchers have begun to conduct studies on GDM to find out the possible factors that could lead to GDM and the consequences the mother and offspring might encounter like type 2 diabetes in mother and infant, macrosomia in newborns, metabolic syndrome in children etc. One specific factor that researchers are debating on are the links between excess gestational weight gain, maternal overweight/obesity, and its relation to GDM. Some researchers have conducted studies which prove that there is a link between excess gestational weight gain, maternal overweight/obesity and its relation to GDM. The sources obtained for my research paper are peer-reviewed academic journal articles and peer-reviewed reviews written by medical researchers, doctors, and engineers from different universities. Some common medical terms used in the following journal articles are: gestational diabetes, BMI, Macrosomia, LGA, Metabolic Syndrome, and Oral glucose tolerance test. BMI is referred to as Body Mass Index which is the measure of a humans body shape by dividing a

persons mass (kg) by a persons height (m). Macrosomia is defined as excessive body weight on a newborn. LGA stands for large-gestational-age which is a baby who has a gestational age above [4000 grams.] According to the U.S. Department of Health and Human Services, Metabolic Syndrome is a collective name for a group of risk factors that increase your chances of having heart disease and other serious health problems like diabetes and stroke. The last term used frequency is Oral glucose tolerance test (OGTT) which is when a pregnant women is administered a dose of glucose and then blood samples are drawn afterwards to determine how quickly it takes for the glucose to clear from the blood. This annotated bibliography is designed for students, pregnant mothers with or without GDM as a brief overview of the effects that obesity and Gestational Diabetes Mellitus may have on mothers and their infants. As with the rising prevalence of obesity, recent studies have highlighted the increased risk associated with obesity in pregnancy, including increased risks of cesarean delivery, stillbirth, hypertensive disorders of pregnancy, fetal structural malformations, and gestational diabetes (Roman et al 2011). The time period for relevant research is about twelve to ten years as there has become an increase in cases of obese pregnant mothers with GDM. Aviram, A., Hod, M., & Yogev, Y. (2011). Maternal obesity:Implications for pregnancy outcome and long-term risks-a link to maternal nutrition.International Journal of Gynecology and Obstetrics, 115s6-s10.doi:10.1016/S0020-7292(11)6004-0 In this peer-review reviewed, the authors, medical researchers from the Department of Obstetrics and Gynecology, Helen Schneider Hospital for Women in Petah Tiqva, Isreal, review ample studies about how obesity has increased over the years and the effects it has

had on pregnancy outcomes like gestational diabetes. According to the data the authors have collected obesity among pregnant women is now between 18.5 to 38.3 percent (S6). Women that are obese are more prone to pregnancy complications like gestational diabetes, pregnancy hypertensive disorders, higher rates of cesarean deliveries, slower labor progression while the infant might be prone to LGA, stillbirth and adolescent complications such as diabetes and obesity (S6). The authors found that prepregnancy overweight and obesity were associated with adverse pregnancy outcome in glucosetolerant women (S7). The authors found that in some studies a 2-10 fold increase in gestational diabetes mellitus among obese pregnant women (S7). The authors also found that a high maternal weight or BMI accounted for the association between birth weight and adult adiposity [fat deposit] (S8). Based off the studies collected, the authors suggest that women who are obese obtain early screening in order to prevent future complications and recommend a healthy diet plan and physical exercise because they found in a similar study that when an obese pregnant mother exercised daily, she had lower rates of GDM (S9). This review is relevant to my topic in that it uses ample amount of studies to show the health risks that GDM and obesity have on pregnant mothers and their infants. Black, M., Sacks, D. A., Xiang, A. H., & Lawrence, J. M. (2013). The Relative Contribution of Prepregnancy Overweight and Obesity, Gestational Weight Gain, and IADPSG-Defined Gestational Diabetes Mellitus to Fetal Overgrowth. Diabetes Care, 36, 56-

62.doi:10.2337/dc12-0741 In this journal article, the authors, medical researchers, evaluate whether prepregnancy overweight and obesity among women with or without GDM effects fetal overgrowth

(56). Prior to this study, the International Association of Diabetes and Pregnancy Study Groups- defined gestational diabetes mellitus and maternal overweight and obesity as being associated with increased risk for adverse maternal and perinatal outcomes, such as fetal overgrowth, shoulder dystocia and birth injury, pre eclampsia, and preterm delivery(56). In response to this statement the authors conducted this study. The authors created six groups: 1) normal weight, no GDM 2) normal weight, GDM 3) overweight, no GDM 4) overweight, GDM 5) obese, no GDM, and 6) obese, GDM (57). The overall results concluded that 5,851 (59.5%) women were overweight or obese and 1,892

(19.2%) had GDM. Out of those with GDM, 1,443 (76.3%) were overweight or obese. Among women without GDM, 21.6% of LGA infants were attributable to maternal overweight and obesity, and the combination of being overweight/obese and having GDM accounted for 23.3% of LGA infants (56). The authors were able to conclude that by increasing gestational weight gain that the rate of LGA in infants increased (61). The authors state that an intervention which would help overweight or obese women lose weight before pregnancy and/or control weight gain during pregnancy, whether or not they have GDM or not, would help lower the risk of their offspring from being an LGA infant or other adverse outcomes (61). This is relevant to research topic in that it shows that women who are linked to GDM and are overweight or obese increase the chance that their offspring might have adverse outcomes (61). Boney, C.M., Verma, A., Tucker, R., & Vohr, B. R. (2005). Metabolic Syndrome in Childhood:Association With Birth Weight, Maternal Obesity, and Gestational Diabetes Mellitus. Pediatrics, 115(3), e290-e296.doi:10.1542/peds.2004-1808

In this journal article, medical researchers from the Department of Pediatrics, created a study to determine whether children who were LGA at birth and offspring of mothers with or without GDM are at increased risk for developing the MS in childhood(e291). Metabolic Syndrome (MS) is defined by the authors as the association of obesity, insulin resistance, glucose intolerance, hypertension, and a characteristic dyslipidemia (e291). This study was involved testing children at the age of 6, 7, 9, and 11 years old. The study consisted of four groups: 1) LGA offspring of mothers without GDM 2) LGA offspring of mothers with GDM 3) AGA (appropriate-for-gestational age) offspring of mothers without GDM 3) AGA offspring with mothers with GDM. The authors measured the childrens glucose tolerance, weight, insulin and high-lipoprotein cholesterol levels. According to the National Cholesterol Education Program, if three of the five components during the five year study period show up in the children then those children would be considered as having Metabolic Syndrome (e293). In the study 15 percent of the children in the LGA/GDM group at the age of 11 had three components meeting the conventional definition of Metabolic Syndrome compared to the 3 to 5.3 percent of children showing three of the components in the other groups (e293). The authors concluded that LGA offspring of diabetic mothers were at significant risk of developing Metabolic Syndrome in childhood (e290). This study is relevant to the research study in that it demonstrates the effects offspring may encounter later in life with mothers that were considered to have maternal obesity, GDM and an increased gestational age weight. Chu, S.Y., Callaghan, W. M., Kim, S. Y., Schmid, C. H., Lau, J., England, L. J., & Dietz, P.M. (2007). Maternal Obesity and Risk of Gestational Diabetes Mellitus. Diabetes Care, 30(8), 2070-2076.doi:10.2337/dc06-2559a

In this scholarly journal article, the authors, medical researchers from the American Diabetes Association, collected information from twenty studies on the increase of maternal weight gain and the link between gestational diabetes mellitus and comprised it into a meta-analysis. The authors collected data from three sources: a PubMed search of relevant articles from January 1980 to January 2006;a reference lists of publications selected from the PubMed search; and reference lists of review articles on obesity and maternal outcomes published between January 2000 and January 2006 ( 2070). The authors findings resulted in a link between high maternal weight and high risk of GDM (2070). The results led the authors to conclude that the consequences associated with obesity and GDM, including higher risk of adverse infant outcomes, higher risk of diabetes for the mother later in life, and a higher risk of diabetes and overweight for the offspring(2073). The authors suggest that in order to prevent GDM and type 2 diabetes in obese women that the young pregnant mothers must maintain a healthy nutritional diet and physical exercise (2074). This meta-analysis is of relevance to the research project in that it uses previous studies to show the link between obesity and gestational diabetes and the consequences the mother and the offspring might face. Gandhi, P., & Farrell, T. (2011). Gestational diabetes mellitus (GDM) screening in morbidly obese pregnant women . European Journal of Obstetrics & Gynecology and Reproductive Biology, 159(2), 329-332.doi:10.1016/j.ejogrb.2011.09.015 In this journal article, the authors, medical researchers from the Department of Obstetrics and Gynecology, created a study in which they do early screenings for morbidly obese women to check for Gestational Diabetes Mellitus. The test consisted of 190 pregnant women who met the requirement of having a BMI of greater than or equal to 40 kg/m .

The authors administered a 75 g oral glucose tolerance test (OGTT) to the pregnant women who were 20 weeks along in their pregnancy. This same test again when the pregnant women were 28 weeks along in their pregnancy. Of the 190 women included in our study, GDM was diagnosed in 46 (24%) women. Thirty-two (70%) were identified at the initial 20 week OGGT and 14 (40%) were diagnosed following the 28-week test (330). These results suggest to the authors that pregnant women with a BMI greater than 30 between 24 and 28 weeks should be screened for GDM (331). The authors state that as a pregnant womens BMI increases so does their insulin resistance so it is better to be screened early before the persons insulin resistance is too high. The authors make the conclusion that by getting screened early, than an early intervention can take place like creating a dietary plan, applying oral hypoglycemic agents and insulin if needed, and maintaining a healthy glycemic level (331). By detecting GDM early, it lowers the risks that the pregnant mothers and offspring might encounter during birth and post-delivery (331). This is relevant to the research topic in that it shows statistically that women who are obese have an increased change of developing GDM and by detecting GDM early it can lower the consequences both mother and offspring might encounter. Gillman , M., Rifas-Shiman, S., Berkey, C. S., Field, A. E., & Colditz, G. A. (2011). Maternal Gestational Diabetes,Birth weight, and Adolescent Obesity. Pediatrics,111(3), e221e226. In this scholarly article, the authors, medical researchers from the Departments of Nutrition and Epidemiology, created a study where they surveyed 7981 girls and 6900 boys, 9 to 14 years of age. The purpose of this study was to see if the effects of GDM had an influence on birth weight or by maternal adiposity (e221). The authors sent out

questionnaires with questions that asked the participants about height, weight, diet, activity and then compared the information with their mothers information such as GDM, height, current weight, and childs birth weight (e221). The study found that among the 465 participants whose mothers had GDM, 17.1% were at risk for overweight and 9.7% were overweight (e223). The authors concluded that GDM may be only a risk marker for offspring obesity, not in the causal pathway (e224). The authors state Although our results do not implicate GDM as a sufficient cause of offspring obesity, they may be consistent with GDMs programming the fetus for later, postnatal influences that lead to obesity (e224). However, the authors did notice that offspring who were exposed to diabetes in utero had higher BMI than their unexposed siblings (e224). This information is relevant to my research in that it studies the relationship between GDM and the consequences the offspring might encounter like obesity. The study showed that there might be a link between mothers with GDM and their offspring experiencing weight imbalances. Also, this study shows that by lowering GDM in pregnant mothers then it might lower the chances of children from becoming obese. Hadar, E., & Hod, M. (2009). Gestational Diabetes Mellitus: A Review. Current Medical Literature: Diabetes, 26(1), 1-8. In this peer-reviewed review, the authors, medical doctors from the Helen Schneider Hospital for Women in Petah-Tiqva, Israel, state the statistics, taken from previous studies, on the effects of mothers with GDM and the consequences that their offspring might encounter. The authors also suggest different treatments that could be helpful for mothers with GDM. According to the authors, GDM accounts for 90 -95 percent of

diabetes occurring in pregnancy and offspring of mothers with GDM have an increased risk of having future insulin resistance (1). The authors also found that pre-pregnancy obesity and diabetes independently increase the risk of cesarean section delivery(1). One major concern associated with women with GDM is the increased risk of developing type 2 diabetes, which has been the case in the range of 20-80 percent (1). It has shown that there is in increased risk in births resulting in stillbirth, abnormal fetal growth, birth trauma and many other metabolic disturbances to infants born to mothers with GDM (1). In previous studies, it has shown that there has been a rise of 20-45 percent in infants with macrosomia born to mothers with GDM (2). The authors continue on to discuss different treatments for patients with GDM. One of the most important treatments that can be done is to maintain a near-normal metabolic control (3). The authors suggest that this can be done by developing a healthy diet which is monitored by a doctor and daily exercise. This article is relevant to the research topic in that it states the statistical effects that GDM has not only on the mother but the offspring. Hedderson, M. M., Gunderson, E. P., & Ferrara, A. (2010). Gestational Weight Gain and Risk of Gestational Diabetes Mellitus. Obstetricians and Gynecologists, 115(3), 597-604. In this scholarly journal article, the authors, medical researchers from Kaiser Permanente Medical Care Program of Northern California, created a study to test whether an increase in gestational weight gain was associated with an increase in Gestational Diabetes Mellitus (GDM). Prior to their test, the Institute of Medicine in 2009 reported that there was a lack of evidence supporting that there was a link between gestational weight gain and GDM (597). In response to this report, the authors created a case-controlled study where they had 345 women with GDM and 800 women in the control group, who had

given birth between January 1, 1996 and June 30, 1998 (598). The women were screened for GDM at 24-28 weeks of gestation (597). The results consisted of that the risk of GDM increased with increasing rates of gestational weight gain(597). The results showed that GDM would mostly likely be from nonwhite race/ethnicity group, to be older than 35 years, to have a family history of diabetes, to have hypertension at the first prenatal visit, to have had two or more prior live births, and to be overweight or obese before pregnancy(599). The authors found that the link between gestational weight gain and the risk of GDM was mainly attributable to excessive weight gain in the first trimester (603). The authors study was one of the first studies to support the link between gestational weight gain and the risk of GDM (603). This article relates to the research project because it emphasizes the idea that obesity is linked to the increase in GDM in pregnant women which could be lowered with a proper diet. By maintaining a healthy diet, it can lower the risk of obtaining GDM which would lower the risk of a pregnant womans offspring developing type 2 diabetes mellitus (597). Joy, S., Roman, A., Istwan, N., Rhea, D., Desch, C., Stanziano, G., & Saltzman, D. (2012). The Effect of Maternal Obesity on Pregnancy Outcomes of Women with Gestational Diabetes Controlled with Diet Only, Glyburide, or Insulin. American Journal of

Perinatology, 29(8), 643-648. doi: 10.1055/s-0032-1314884 In this journal article, the authors, medical researchers from the Department of Maternal Fetal Medicine at Carolinas Medical Center, conducted a study on the effects of maternal obesity with women diagnosed with Gestational Diabetes Mellitus and different ways to treat GDM like diet only, glyburide, or insulin. OHA (Oral Hypoglycemic agent) glyburide is a drug used to help patients with type 2 diabetes. The authors used women

with GDM and broke them up into two groups: obese and non-obese and then in each group the women were broken down into subgroups: diet only (3918 women); OHA glyburide (873 women); and insulin (2,229 women). The study resulted in that the obese group had a higher risk with birth complications (644). The authors found that adverse maternal and neonatal outcomes are greater in obese women, even if they are able to control their GDM with diet alone (646). This suggested to the authors that there needs to be other treatments that will help obese women with GDM. The authors suggested that medications such as OHA or insulin should be taken to help manage the patients with GDMs blood glucose levels (646). This study is relevant to the research project in that it conducted a study to demonstrate the link between obesity and GDM and the consequences from it. The study also showed how in some cases diet alone will not help a patient with GDM, that other medications can be more useful. Landon, M. B., & Gabbe, S. G. (2011). Gestational Diabetes Mellitus. Obstetrics and Gynecology, 118(6), 1379-1393.doi:10.1097/AOG.0b013e31823974e2 In this scholarly journal article, medical researchers from The Ohio State University College of Medicine: Department of Obstetrics and Gynecology, discuss the screening and diagnosing process of Gestational Diabetes and factors that might influence the increase of GDM. The authors describe GDM as a heterogeneous group of metabolic disorders, which result in varying degrees of maternal hyperglycemia and pregnancyassociated risk (1379). The authors found that there was a prevalence of GDM found in women of ethnic groups that have high frequencies of type 2 DM, including women of Hispanic, African, Native American, Asian, Pacific Island ancestry and an increase of GDM in women that are overweight (1379). The authors discuss how by maintaining a

nutritional dietary plan can help reduce GDM (1385). The authors concluded that a diet composed of 50-60% carbohydrates will often result in excessive weight gain and postprandial hyperglycemia(1385). That is why it is suggested that a diet consisting of a carbohydrate intake of about 33-40% of calories would be best in women that are pregnant (1385). The authors conclude that a specified carbohydrate limited diet in obese women with GDM improves glycemic control and reduces weight gain (1385). An increase of about 15 pounds in gestational weight gain can also increase the risk of preterm delivery, macrosomia, and cesarean delivery (1385). This article emphasizes that it is important for pregnant women with or without GDM to maintain a healthy diet in order to lower their risks of a complicated birth and complications after post birth. O'Dwyer, V., Farah, N., Hogan, J., O'Connor, N., Kennelly, M.M., & Turner, M. J. (2012). Timing of screening for gestational diabetes mellitus in women with moderate and severe obesity. Acta Obstet Gynecol Scand, 91(4), 447-451.doi:10.1111/j.1600-

0412.2011.01324.x In this scholarly journal article, the authors, medical researchers from University College Dublin Centre for Human Reproduction, created a study on screening moderate and severe obese pregnant women for gestational diabetes. Prior to the authors study, it was reported in previous studies that the risk of GDM is increased with obesity, based on a body mass index (BMI)> 29.9 kg/m (447). The material and methods used in this study were: 92 white European women with a BMI greater than 34.9 9 kg/m whose maternal weight and BMI were calculated and an dating ultrasound was performed to confirm gestational age and a singleton ongoing pregnancy (448). Women were given an oral glucose tolerance test (OGTT) before 20 weeks gestation and if the results came back

normal then another OGTT was administered at 28 weeks gestation (448). The authors found that nearly one in five women with moderate or severe obesity had an abnormal OGTT when screened for GDM(449). The authors purpose for conducting this stu dy was to evaluate screening with a diagnostic OGTT earlier than the standard 28 weeks gestations in women with moderate or severe obesity (BMI> 34.9% kg/m) who are at high risk of developing GDM (448). In about 20 previous studies the authors found that the risk of developing GDM was about two, four, and eight times higher among overweight, obese, and severely obese women respectively (448). This study is

conclusive with the previous studies mentioned in this paper stating how obesity increases pregnant womens chances of having GDM, which as a result could cause not only complications for the mothers but also the offspring. Olmos, P., Borzone, G., Olmos, R., Valencia, C. N., Bravo, F., Hodgson, M., Belmar, C., Poblete, J, Escalona, M., & Gomez, C. (2012). Gestational diabetes and pre-pregnancy overweight:possible factors involved in newborn macrosomia. Journal of Obstetrics and Gynaecology Research, 38(1), 208-214.doi:10.1111/j.1447-0756.2011.01681.x In this scholarly journal article, the authors, medical and engineering researchers from Pontificia Universidad Catolica de Chile, study the effects of glycemic control, pre pregnancy body mass index and gestational weight gain per week on the frequency of macrosomia in women with GDM (208). Macrosomia or large-for-gestational-age (LGA) in infants, which causes fetal hyperinsulinemia, in cases due to gestational diabetes mellitus has a positive connection with neonatal excess body mass of the mother (208). The authors studied 251 GDM pregnancies and separated them into two groups: the non-overweight group (more than 25.0 kg/m) with 125 women and the

overweight group (less than or equal to 25.0 kg/m) with 126 women. The statistical analysis was carried out using the Students t-test and -test, receiver-operator characteristic curves and linear and binary logistic regressions (208). The study resulted in that macrosomia rates were 10.4% in the non-overweight group and 24.6% in the overweight group (210). These results suggested to the authors that good glycemic control in GDM patients was not enough to reduce macrosomia to acceptable limits (208). After the study, the authors suggested that, in order to further reduce the incidence of LGA infants in GDM, in addition to tight glycemic control during pregnancy in all patients, counseling and treatment for overweight and obese women is needed, encouraging them to aim for a BMI below 25.0 kg/m before becoming pregnant(213). This article is of importance to the research project in its way of demonstrating that obesity is a major factor in the increase of pregnant woman with GDM and how this increase affects the offspring of those mothers with GDM. Ornoy, A. (2011). Prenatal origin of obesity and their complications: Gestational diabetes, maternal overweight and the paradoxical effects of fetal growth restriction and macrosomia. Reproductiv Toxicology, 32(2) 205-212.doi:10.1016/j.reprotox.2011.05.022 In this peer-reviewed review, Asher Ornoy, medical researcher from Hebrew University Hadassah Medical School, discusses the effect that obesity has on pregnancy complications and the links between obesity and gestational diabetes. Ornoy begins by discussing how over the last several decades there has been a dramatic increase in the amount of overweight and obese adults (205). After reviewing many studies, Ornoy found that maternal gestational Diabetes Mellitus and obesity are associated with fetal macrosomia, [and] are also very strong predictors for the development of the metabolic

syndrome, especially if the newborn is LGA (207). Ornoy found that with children with mothers who had GDM, there was a higher rate of overweight/obesity during childhood and adolescence compared to children with mothers who did not have GDM (207). Ornoy studied a case-study done by Yogev and Visser, where they found that the rate of GDM in obese pregnant women is as high as 25 percent (208). In this review, Ornoy suggest that a by maintain a healthy dietary control, and getting physical exercise will help lower the complications not only in mothers with GDM and maternal obesity but also help the infants from encountering a glucose imbalance and from becoming obese (211). This review was relevant to the research topic in that it used many studies to show the effects that obesity and GDM have not only on mothers but also their infants. Roman, A. S., Rebarber, A., Fox, N. S., Klauser, C. K., Istwan, N., Rhea, D., & Saltzman, D. (2011). The effect of maternal obesity on pregnancy outcomes in women with gestational diabetes. Journal of Maternal-Fetal & Neonatal Medicine, 24(5), 723-

727.doi:10.3109/14767058.2010.521871 In this journal article, the authors, medical researchers from Maternal Fetal Medicine Associates and Alere Womens and Childrens Health, study the impact of maternal obesity on maternal and neonatal outcomes in pregnancies complicated with gestational diabetes mellitus (723). The authors collected 3798 patients from July 2000 and July 2009 that were diagnosed with GDM. The authors calculated the maternal pre-pregnancy BMI and blood glucose level and broke the women into five groups: underweight (518.5 kg/m), normal weight (18.524.9 kg/m), overweight (2529.9 kg/m), obese (3039.9 kg/m), and morbidly obese (40 kg/m) (724). Out of the 3,789 women with GDM, 2,028 were considered non-obese while 1,770 were considered obese. The authors found

that that an increase in hostile maternal and neonatal outcomes with obese women when compared to the non-obese women (724). The authors also found that if women had a BMI greater than 40, then their risk of having GDM increased (725). This result led the authors to come to the conclusion that as the pregnant womens BMI increased so did the risk of composite neonatal complications (724). The authors state that their findings were consistent with prior studies in that both found that the combination of obesity and GDM is associated with an increased risk of adverse pregnancy outcomes and pregnancyrelated hypertension (726). The authors support the notion of reducing BMI in pregnancy to a normal state in order to lower the risk of hostile pregnancy outcomes (726). This study is relevant to the research topic in that it studies the direct link of GDM and obesity and the consequences of having GDM.

Shin Y., K., Saravia, C., Curtis, M., Wilson, H.G., Troyan, J., England, L., & Sharma, A.J. (2013). Fraction of Gestational Diabetes Mellitus Attributable to Overweight and Obesity by Race/Ethnicity, California, 2007-2009. American Journal Of Public Health, 103(10), e65-e72.doi:10.2105 In this scholarly journal article, the authors discuss the results from their study on the influences on Gestational Diabetes. The authors define Gestational Diabetes Mellitus (GDM) as, carbohydrate intolerance leading to hyperglycemia with onset or first recognition during pregnancy (65). The authors created a study where they analyzed 1,228,265 records of women that were 20 years or older in California during 2007-2009 (65). Previous to their study it was found that women of American Indian, Hispanic, and Asian heritage had the highest recorded estimate of GDM (65). In response to this

record, the authors felt that the increase in GDM might be from an increase in overweight and obesity among women of reproductive age (65). the authors created this study to estimate the contribution of BMI to GDM risk across different racial/ethnic groups by calculating the race/ethnicity-specific percentages of GDM attributable to prepregnancy overweight and obesity(65). The authors determined if the women

included in the study had GDM by using data from both the birth certificate and hospital discharge record (66). The results came back as that overweight and obesity both increased from 45.6% in 2007 to 47.3% in 2009. The results also showed that overweight/obesity was higher among American Indian (61.7%), Black (56.5%), and Hispanic (56.3%) women compared with White (38.7%) and Asian/Pacific Islander (22.9%). This article is of relevance to the research project in its claim made by the authors that the increase in GDM can be lowered with diet modifications and excerise. Obesity is a major factor in the increase of GDM which can be lowered by daily exercise and a healthy diet. Yogev, Y., & Visser, G. H. A. (2009). Obesity, gestational diabetes and pregnancy outcome.Seminars in Fetal & Neonatal Medicine, 14, 77-84. In this peer-reviewed review, the authors, medical researchers from Tel Aviv University, discuss the connections between obesity and gestational diabetes and the possible pregnancy outcomes. According to the authors, it is universally acknowledged that maternal overweight and obesity are linked with adverse pregnancy outcomes (78). The authors also found that about 3 to 15 percent of women develop GDM during pregnancy (80). Yogev et al in a study of 6857 women, found a direct association between glucose screening categories, obesity and the rate of GDM(81). From previous

studies, the authors suggested that GDM, especially in combination with pre-pregnancy obesity, predicts a subsequent syndrome of high cardiovascular risk which shows that GDM as a predictor for the development of Metabolic Syndrome (82). The authors define Metabolic Syndrome as a group of abnormalities that increase the risk for cardiovascular diseases (81). In conclusion, the authors were able to find that obesity is associated with GDM which has shown an increase in adverse pregnancy outcomes (82). The authors also concluded that GDM is the most important marker for future development of metabolic syndrome (82). This review is relevant to the research topic in that it uses ample amount of studies to show the link between obesity and GDM and the consequences that result from GDM.