!"#$" &'()( #* +,(-.,-" /,0'1,.

2

Cesaiean iates aie incieasing woiluwiue. In the 0niteu States, the cesaiean iate
incieaseu by SS% fiom 1996 to 2uu7, ieaching the highest iepoiteu cesaiean iate of
S2%
12
. Between 199u anu 2uu8, Englanu has seen a 1uu% inciease in biiths
ueliveieu by cesaiean section. Baseu on the known iisks of cesaiean ueliveiies foi
both mothei anu chilu, the Woilu Bealth 0iganization iecommenus that the
cesaiean section iate iemain unuei 1S%. Nany countiies iepoit iates above the
WB0 iecommenuation, such as China with a 6u% cesaiean section iate, Biazil with
a 47% cesaiean section iate, anu Englanu with a 2S.8% cesaiean section iate
2
.


0f all the methous of ueliveiy, cesaiean sections aie associateu with the
highest iates of infant moitality anu moibiuity, as well as an incieaseu iisk of low
Apgai scoies at one minute, uifficulty bieathing, hypoglycemia, anu a longei peiiou
spent in the neonatal intensive caie unit
2
. Although shoit-teim mateinal anu infant
iisks of cesaiean ueliveiy aie consistently iecognizeu anu communicateu with
motheis, long-teim complications aie less often consiueieu
7
. Cesaiean ueliveiy has
been associateu with long-teim complications such as lowei immune iesponse,
leauing to an incieaseu iisk of asthma, neuioenuociine uisoiueis, metabolic
uisoiueis, anu uiabetes
7-8
.


+3..,"4 &,(,-.56

In the 0niteu States, moie than one-thiiu of auults aie obese anu the obesity
iates among chiluien have neaily tiipleu since 198u
1S
. 0besity is associateu with
many chionic conuitions such as inflammation, type II uiabetes, hepatic steatosis,
anu caiuiovasculai uisease
1u
. uiven the iise in obesity iates anu cesaiean iates,
Amanda Schmitt 3/30/14 6:13 PM
Comment [1]: Is this the title of youi
papei oi just this section.
Amanda Schmitt 3/30/14 6:16 PM
Comment [2]: Nice use of a chait!
Inteiesting that it uippeu uuiing the 9us anu
incieaseu in the 2uuus
Amanda Schmitt 3/30/14 6:12 PM
Comment [3]: You might want to biiefly
uesciibe this test foi ieaueis that uo not
know about what it entails
scientists have iecently begun speculating an association between cesaiean ueliveiy
anu futuie iisk of obesity.

!"#"$%&' )'$) &*+&,-.". +* $##*&/$)/*+0

A Biazilian stuuy concluueu that young auults, who hau been boin by
cesaiean ueliveiy, hau a S8% highei pievalence of obesity than young auults who
hau been ueliveieu vaginally. This piompteu ieseaicheis to analyze thiee Biazilian
biith cohoits to ueteimine if cesaiean ueliveiies leau to incieaseu iisk of obesity in
chiluhoou, auolescence, anu eaily auulthoou. Initial analyses suggesteu that
inuiviuuals boin by cesaiean section hau about a Su% highei pievalence of obesity.
Bowevei, aftei aujusting foi possible confounuing vaiiables, such as family income,
type of payment foi ueliveiy (coveieu by health caie, piivate health insuiance,
piivate piactice), mateinal age, smoking uuiing piegnancy, mateinal euucation,
mateinal piepiegnancy weight, mateinal height, anu biith weight, the association
was no longei significant
S
.
In a ietiospective cohoit stuuy, ieseaicheis suiveyeu fifth giaue stuuents
anu theii paients looking foi an association between cesaiean ueliveiy anu
chiluhoou obesity. Aftei contiolling foi a iange of possible confounuing vaiiables,
the stuuy showeu no causal association between cesaiean ueliveiy anu obesity in
chiluien in fifth giaue. This stuuy suggests that mateinal piepiegancy weight may
be the confounuing vaiiable iesponsible foi this association. 0bese motheis aie
moie likely to have a iequiieu cesaiean section uue to incieaseu soft tissue,
complications uuiing laboi, anu fetal maciosomia. 0veiweight anu obese
piepiegnancy weight is associateu with chiluhoou obesity anu may be iesponsible
foi the association between cesaiean ueliveiy anu obesity, as othei stuuies may
have not aujusteu foi mateinal piepiegnancy BNI
S
.

!"#"$%&' )'$) #-11*%)# $+ $##*&/$)/*+0

In one piospective cohoit stuuy, ieseaicheis examineu the ielationship
between moue of ueliveiy anu obesity in chiluien at thiee yeais of age. 0f the 1,2SS
live biiths, 22.6% weie ueliveieu by cesaiean section anu 77.4% by vaginal biith.
Neasuies of obesity incluueu mateinal pie-piegnancy BNI, biith weight foi
gestational age, bieastfeeuing uuiation, anu skinfolus. The mean mateinal pie-
piegnancy BNI was highei foi infants ueliveieu by cesaiean section than those
infants ueliveieu vaginally. Buiation of bieastfeeuing was shoitei foi cesaiean
ueliveieu infants. Infants boin by cesaiean ueliveiy also hau a highei mean BNI at
age thiee anu gieatei skinfolu measuiements. Fuitheimoie, infants ueliveieu by
cesaiean section weie moie likely to be oveiweight by age thiee than chiluien
ueliveieu vaginally. 0veiall, the ieseaicheis founu that at age thiee, chiluien
ueliveieu by cesaiean section hau twice the likelihoou of obesity, as well as highei
BNI anu skinfolu measuiements, than chiluien ueliveieu vaginally. The ciitical
aspect of this stuuy is its contiol ovei potentially ciucial confounuing vaiiables such
as mateinal BNI anu biith weight
1
.
Amanda Schmitt 3/30/14 6:18 PM
Comment [4]: veiy goou intiouuction to
the mateiial! Lets the auuience know what
they aie about to ieau
Amanda Schmitt 3/30/14 6:23 PM
Comment [5]: Nice use of
assimilationsynthesis
Anothei stuuy examineu the ielationship between cesaiean ueliveiy anu the
iisk of oveiweight anu obesity in sixth giaue chiluien. Taking into account possible
confounuing vaiiables, the stuuy founu that chiluien ueliveieu by cesaiean section
weie twice as likely to be oveiweight oi obese than vaginally ueliveieu chiluien.
This stuuy fuithei examineu the association in ielation to males anu females,
uiscoveiing that males ueliveieu by cesaiean section weie at an incieaseu iisk foi
oveiweight anu obesity, while females ueliveieu by cesaiean section weie at an
incieaseu iisk foi oveiweight only
6
.
0ne meta-analysis evaluateu the stiength of the association between
cesaiean ueliveiy anu oveiweight anu obesity in auolescents anu auults, while
investigating the hygiene hypothesis as a possible unueilying mechanism to the
association. This stuuy contiolleu foi possible cofounuing vaiiables such as
mateinal obesity anu infant biith weight. Aftei ieviewing 7 cohoit stuuies anu 2
case-contiol stuuies that met the inclusion ciiteiia, the ieseaicheis concluueu that
inuiviuuals ueliveieu by cesaiean section hau a SS% incieaseu iisk of oveiweight
anu obesity as auolescents anu auults
7
.
Anothei systemic ieview anu meta-analysis of the effect of cesaiean section
anu vaginal ueliveiy on offspiing BNI evaluateu stuuies that hau iepoiteu biith
chaiacteiistics anu long-teim follow-up. Analysis of these fifteen stuuies leu to the
conclusion of a stiong association between cesaiean ueliveiy anu oveiweight anu
obesity in auulthoou. This meta-analysis uemonstiates a ieuuceu association
between cesaiean ueliveiy anu BNI in oluei subjects, suggesting that exposuie to
enviionmental factois thioughout life incieases with age, concealing the association
in oluei subjects. In auuition, this analysis suggests that futuie ieseaich is neeueu to
ueteimine whethei the association is causal oi ieflective of confounuing vaiiables,
such as the iising iates of cesaiean section ueliveiies
2
.
In Biazil, cesaiean ueliveiy is associateu with high economic status, anu
cesaiean section iate has incieaseu fiom 1S% in 197u to Su% in 2u11
8
. 0ne stuuy
assesseu two Biazilian cohoit stuuies fiom uiffeient socioeconomic backgiounus foi
the association of cesaiean ueliveiy anu incieaseu BNI anu obesity in school
chiluien. 0ne cohoit was boin in a wealthy city, anu the othei cohoit was boin in a
less wealthy city. The obesity iate in the wealthy city, Ribeiiao Pieto, was 1S.u% anu
2.1% in the less wealthy city of Sao Luis. The association between cesaiean ueliveiy
anu obesity iemaineu significant in Ribeiiao Pieto aftei aujusting foi confounuing
vaiiables such as mateinal euucation, smoking uuiing piegnancy, uuiation of
bieastfeeuing, biith weight, anu, only in Sao Luis, pie-piegnancy mateinal weight
8
.
This suggests a socioeconomic factoi that may influence the association between
cesaiean ueliveiy anu iisk of obesity.

+6-00,"7,( -"8 9343., :;;#.43"'4',(

Recent stuuies have iaiseu consiueiable uebate suiiounuing the association
between cesaiean ueliveiy anu obesity in offspiing
8
, as some stuuies have
concluueu that an association exists while otheis have not. I suspect that this
uisciepancy is a iesult of uiffeiences in methous, specifically in the contiolleu
vaiiables. 0ne stuuy that founu no association between cesaiean ueliveiy anu
Amanda Schmitt 3/30/14 6:26 PM
Comment [6]: Exact iesults as the stuuy
befoie this! Inteiesting
Amanda Schmitt 3/30/14 6:29 PM
Comment [7]: What is the hygience
hypothesis.
Amanda Schmitt 3/30/14 6:32 PM
Comment [8]: uoou insight!
obesity suggesteu that piepiegnancy weight may be the iesponsible factoi causing
the association
S
. Bowevei, anothei stuuy contiolleu specifically foi mateinal
piepiegnancy weight anu concluueu that chiluien ueliveieu by cesaiean section hau
uouble the iisk of obesity as compaieu to chiluien ueliveieu vaginally
1
. In auuition, I
suspect that uisciepancies exist uue to the uiffeient ages of the inuiviuuals at the
time they weie assesseu oveiweight anu obesity. 0ne stuuy examineu the iisk foi
obesity uue to cesaiean ueliveiy by evaluating chiluien at age thiee yeais
1
, anothei
stuuy evaluateu fifth giaue chiluien
S
, anu anothei stuuy evaluateu auolescents anu
auults
7
. I suggest that futuie stuuies contiol foi the same vaiiables anu evaluate
theii cohoits at the same age oi ages in oiuei to obtain a seiies of iesults with
similai conuitions. This will allow ieseaicheis to ueteimine if a cofounuing vaiiable
is iesponsible foi the association, oi if an association uoes exist, the age oi ages that
inuiviuuals aie at the gieatest iisk of obesity as a iesult of cesaiean section.

Although the ieseaich assessing the association between cesaiean ueliveiy
anu obesity is faiily new, ieseaicheis aie cuiiently speculating the possible
mechanisms unueilying the association
1
. Some ieseaicheis piopose a biological
mechanism that unueilies the association between cesaiean ueliveiy anu offspiing
obesity. This mechanism is known as the hygiene hypothesis, anu suggests that
infants ueliveieu vaginally gain uiiect exposuie to mateinal miciobiota in the
vaginal anu intestinal tiacts. Infants ueliveieu by cesaiean section aie exposeu to
nonmateinal, enviionmental bacteiia. This uiffeience in initial acquisition of infant
bacteiia may impact gut miciobiota uiveisity anu composition, causing long-teim
complications foi cesaiean-ueliveieu inuiviuuals
7
.
Noue of ueliveiy anu bieastfeeuing influence the composition anu uiveisity
of gut miciobiota. Infants ueliveieu by emeigency cesaiean section, iegaiuless of
being bieastfeu oi exposeu to antibiotics, hau a lowei abunuance of Bacteioiuetes as
compaieu to infants ueliveieu by elective cesaiean section oi vaginally. Bowevei,
the lowei abunuance of Bacteioiuetes was ieuuceu in bieastfeu infants
4
as
bieastfeeuing was associateu with moie uiveisity anu an oveiall gieatei abunuance
of gut miciobiota
4
.
Buman gut miciobiota is pioven to influence host metabolism anu obesity
4
,
as testeu on both humans anu mice
9
. The ielative abunuance of two uominant
gioups of bacteiia in the human gut, Bacteioiuetes anu Fiimicutes, uiffeis between
lean anu obese inuiviuuals; gut miciobiota of obese people contains a lowei
piopoition of Bacteioiuetes, which aie piotective factois against oveiweight anu
obesity
7
, anu a highei piopoition of Fiimicutes than lean people
S,9
.









Amanda Schmitt 3/30/14 6:34 PM
Comment [9]: I woulu place this
infoimation at the fiist mention of the
hygiene hypothesis
Refeiences
1. Buh, S. Y., ") $,. Beliveiy by caesaiean section anu iisk of obesity in pieschool age
chiluien: a piospective cohoit stuuy. 2%&' 3/# 4'/,. 97, 61u-616 (2u12). Web.

2. Baimasseelane, K., Byue, N. }., Santhakumaian, S., uale, C., Noui, N. Noue of
ueliveiy anu offspiing bouy mass inuex, oveiweight anu obesity in auult life: a
systematic ieview anu meta-analysis. 5,*# *+" (2uu6). Web.

S. Flemming, K., Woolcott, C. u., Allen, A. C., veugeleis, P.}., Kuhle, S. The association
between caesaiean section anu chiluhoou obesity ievisiteu: a cohoit stuuy. 2%&' 3/#
4'/,. 98, S26-SS2 (2u1S). Web.

4. Azau, B. N., ") $,. Impact of cesaiean section ueliveiy anu bieastfeeuing on infant
gut miciobiota at one yeai of age. 2,,"%678 2#)'9$ : 4,/+/&$, ;99-+*,*67 1u (2u14).
Web.

S. Baiios, F.C., ") $,. Cesaiean section anu iisk of obesity in chiluhoou, auolescence,
anu eaily auulthoou: eviuence fiom S Biazilian biith cohoits. 29 < 4,/+ =-)% 9S, 46S-
47u (2u12). Web.

6. Wan, L., Alamian, A., Southeilanu, }., Wang, K., Anueison, }., Stevens, N. Cesaiean
section anu the iisk of oveiweight in giaue 6 chiluien. >-% < 5". 172, 1S41-1S47
(2u1S). Web.

7. Li, B. T., Zhou, Y. B., Liu, }. N. The impact of cesaiean section on offspiing
oveiweight anu obesity: a systematic ieview anu meta-analysis. ;+) < ?@"#/)7 S7,
89S-899 (2u1S). Web.

8. uoluani, N. Z., ") $,. Cesaiean section anu incieaseu bouy mass inuex in school
chiluien: two cohoit stuuies fiom uistinct socioeconomic backgiounu aieas in
Biazil. =-)% < 12 (2u1S). Web.

9. Ley, E.R., ") $,A Niciobial ecology: human gut miciobes associateu with obesity.
=$)-%" 444, 1u22-1u2S (2uu6). Web.

1u. Ley, R. E. 0besity anu the human miciobiome. 4-%%"+) ?1/+/*+ /+
B$#)%*"+)"%*,*67 26(1), S-11 (2u1u). Web.

11. uionlunu, N.N., Lehtonen, 0.P., Eeiola, E., Keio, P. Fecal miciofloia in healthy
infants boin by uiffeient methous of ueliveiy: peimanent changes in intestinal floia
aftei cesaiean ueliveiy. < 5"./$)% B$#)%*"+)"%*, =-)% 28(1), 19-2S (1999). Web.

12. Nenackei, F., Bamilton, B.E. Recent tienus in cesaiean ueliveiy in the 0niteu
States. =4CD 3$)$ E%/"F SS (2u1u). Web.

1S. Centeis foi Bisease Contiol anu Pievention (2u1S). 0veiweight anu obesity.
Retiieveu fiom http:www.cuc.govobesity.


To auu in (plus moie!):

In auuition, cesaiean ueliveiy is associateu with a lowei concentiation of umbilical
leptin anu a lowei iate of bieastfeeuing, which have also been associateu with an
incieaseu iisk of oveiweight anu obesity
7
.


Theie is suppoiting eviuence foi the hygiene hypothesis as stuuies have shown an
association between the bacteiial miciobiome anu obesity, as well as othei
metabolic uisoiueis
7
.
0thei uiseases, such as neonatal neciotizing enteiocolitis, inflammatoiy bowel
uisease, anu vaginosis, have been associateu with uistuibances in the miciobiome
7
.
It makes biologic sense evolutionarily that we humans would have found ways
to benefit from our bacterial microbiome, given that the human microbiome
consists of about 100 trillion microbial cells, outnumbering human cells 10 to 1
and in healthy individuals provides a wide range of metabolic functions that
humans lack.

In auuition, cesaiean ueliveiy is associateu with a lowei concentiation of leptin in
the umbilical coiu as well as a uecieaseu iate of bieast-feeuing eaily on; both of
these factois have been associateu with an incieaseu iisk of obesity
7
.
Various interventions to restore a disrupted microbiome have been proposed,
including the use of probiotics. It would be an interesting intervention to try in
infants delivered by cesarean. Perhaps just early skin-to-skin contact could also
be restorative. It has been suggested that a randomized controlled trial of
mode of delivery, with long-term outcomes, is necessary to sort out these
issues. (source 7)

uut miciobiota is consiueieu an enviionmental factoi affecting obesity anu
metabolic uisoiueis
8
.

Reseaicheis have noteu uiffeiences in quantities anu types of bacteiia in infant
intestinal floia ielating to uiffeient moues of ueliveiy
11
.

With the incieasing iates of obesity woiluwiue, iecent ieseaich has associateu
obesity with a shift in composition of gut bacteiia in both humans anu animals
1u
.
uut miciobiota influence metabolism as they impact insulin iesistance,
inflammation, anu auiposity
1u
.
Reseaich on the miciobiome has shown that obesity is associateu with a lack of
Bacteioiuetes anu a gieatei abunuance of genes that metabolize caibohyuiates anu
lipius in the miciobiome
1u
.
Niciobiota affects host auiposity by extiacting eneigy fiom the uiet as well as
influencing the bouy's metabolism as a whole
1u
.

We speculate that the small obesity rate (1.5%) and CS rate (12.4%) in that study could have not
allowed the authors to detect a significant association between CS and obesity, despite the studys
large sample size. In our study, the age difference of the children in the two cities could be partially
responsible for the higher prevalence of obesity in RP compared to SL; however, the prevalences are
too different to be explained by the childrens age only.
http://eds.b.ebscohost.com.ezproxy.neu.edu/ehost/pdfviewer/pdfviewer?sid=0f8da047-89aa-48a5-bd47-
90a89046035d%40sessionmgr115&vid=2&hid=109
In a laige Banish biith cohoit, ieseaicheis uiu not finu a significant association
between cesaiean ueliveiy anu iisk of oveiweight in chiluien ageu 7 yeais.
Bowevei, they noteu an incieaseu iisk of oveiweight in males ueliveieu by cesaiean
section. They also obseiveu that antibiotics auministeieu to infants befoie 6
months of age hau a gieatei iisk of chiluhoou oveiweight in offspiing of noimal-
weight motheis, but a ieuuceu iisk of oveiweight in chiluien of oveiweight oi obese
motheis. I speculate that



Beai Peii,
Excellent stait to youi papei! I likeu how youi fiist section talkeu about many
uiffeient iisks that may be associateu with uiffeiing biith methous. If you aie able
to get the info fiom a souice, I think it might be beneficial anu fuithei suppoit youi
wiiting if in the fiist section (seconu paiagiaph) you inseiteu numeiical uata foi the
iisks of those specific factois uuiing cesaiean vs. vaginal biith. Also, to me it
seemeu like you jumpeu iight into the obese topic without an intiouuction in the
fiist section. You might finu it helpful to auu a concluuing sentence in youi fiist
section talking about obesity as a iisk to help the mateiial flow bettei.
I ieally likeu youi use of a chait! It allows the ieauei to bettei visualize the
subject. If you aie able to finu any moie chaits oi tables, oi pictuies that suppoit
youi aiticle, I woulu uefinitely auu them in!
I think it might be helpful to uefine moie teims in this aiticle, since piegnant
motheis may be ieseaiching about iisks anu not unueistanu the clinical woius useu
in this aiticle. You can eithei uefine them in the aiticle oi put the uefinition in the
maigins, like most of oui textbooks uo.
The oiganization of this aiticle is well uone anu easy to follow. I like how you
sepaiateu suppoiting anu opposing ieseaich. Also youi uesciiption of futuie
oppoitunities is veiy piecise anu uiiect.
0veiall I think this is a gieat stait to youi papei! You seem to be going in a
goou uiiection, so keep up the goou woik! If you have any othei questions feel fiee
to ask me!
Youis tiuly,
Amanua