Running head: INTEGRATIVE LITERATURE REVIEW 1

Integrative Literature Review

Amanda L Rush

Bon Secours Memorial College of Nursing

NUR 4122

April 2, 2018

Christine Turner, PhD, RN

“I Pledge….”
INTEGRATIVE LITERATURE REVIEW 2

Abstract

Purpose: The purpose of this integrated review is to identify the literature that focuses on the

relationship between mothers with gestational diabetes and childhood obesity.

Background: Gestational diabetes mellitus is reported to be associated with childhood obesity

Method: This is an integrative review in which research was collected from online databases.

The articles discussed are quantitative studies that were selected based on specific inclusion

criteria. This information was then used to determine an association between gestational diabetes

and childhood obesity.

Limitations: A significant limitation is the author’s lack of experience in conducting an

integrative review. Other limitations included the criteria used to select the articles such as the

minute time frame.

Results and Findings: The evidence compiled for this integrative review shows both evidence

and absence of a correlation between gestational diabetes and childhood obesity.

Implications and Recommendations: It is recommended that further research be conducted to

confirm or refute a positive correlation.

Integrative Literature Review

The purpose of this integrated review is to identify the literature that focuses on the

relationship between mothers with gestational diabetes and childhood obesity. According to

Hammoud et al., “The prevalence of GDM [gestational diabetes mellitus] is rising worldwide

and the condition is associated with adverse pregnancy outcomes, such as an increased risk of

large-for-gestational age (LGA) neonates and birth complications” (2018). As the epidemic
INTEGRATIVE LITERATURE REVIEW 3

continues, prenatal, perinatal, and postnatal factors could have an impact on childhood obesity

(Zhao et al., 2016).

Education and prevention is key in health. If factors that contribute to a disease process

can be identified early then putting preventative interventions in place could reduce negative

outcomes associated with childhood obesity. The aim of this review is to examine and discuss

published data related to the researcher’s PICO question: Are children of mothers diagnosed with

gestational diabetes during pregnancy at increased risk of developing childhood obesity than

children of mothers who were not diagnosed with gestational diabetes?

Design and Methods

This integrative literature review focuses on five research articles. The search methods

used included the use of PubMed and EBSCO’s Nursing Center Reference Plus databases. The

search words were gestational diabetes and childhood obesity. The results yielded over 67,000

articles. From there, the researcher filtered the search by year, language, peer-review, and

relevance to the PICO question. In terms of date, articles were limited to the years 2013-2017.

Other limiting factors included peer reviewed articles in the English language that were available

in full-text. As a result, almost 18,000 articles remained that met the search criteria.

The articles were chosen based on their relevance to the PICO question, which was, “Are

children of mothers diagnosed with gestational diabetes during pregnancy at increased risk of

developing childhood obesity than children of mothers who were not diagnosed with gestational

diabetes?” The researcher focused on quantitative articles in order to examine finding that met

the inclusion criteria. The total number of articles included after these limitations were applied is

five, with four being quantitative studies (Hammoud et al., 2018; Morgan et al., 2013; Pham,
INTEGRATIVE LITERATURE REVIEW 4

Brubaker, Pruett, & Caughey, 2013; Zhao et al., 2016) and one systematic review and meta-

analysis of literature (Miyazaki et al., 2018).

Findings

The results and findings of three of the five articles clearly identify a direct relationship

between gestational diabetes and childhood obesity (Hammoud et al., 2018; Miyazaki et al.,

2018; Zhao et al., 2016). The results of the two remaining articles identified that there was no

association between gestational diabetes and obesity in childhood (Morgan et al., 2013; Pham,

Brubaker, Pruett, & Caughey, 2013). A summary of the five research articles is presented in

Table 1- Article Evaluation.

Gestational Diabetes Associated with Childhood Obesity

There was a consensus among three of the research articles that there is a positive

association between gestational diabetes and childhood obesity (Hammoud et al., 2018;

Miyazaki et al., 2018; Zhao et al., 2016). In a longitudinal analysis conducted by Hammound et

al. (2018) the authors contacted all mothers with gestational diabetes who delivered at the

University Medical Center, Utrech, the Netherlands between 1990 and 2006. Of those, consent

was obtained for 104 offspring of mothers with gestational diabetes. Infant data was collected

through Dutch infant welfare centers while maternal characteristics were collected from records

of the UMC. From there, a random effects model estimated growth trajectory of offspring of

women with gestational diabetes, concluding that offspring of women with DM are at highest

risk of becoming overweight in early adolescence.

Zhao et al. (2016) conducted a multinational cross-sectional study of 4740 children aged

9-11 in 12 different countries. Appropriate maternal and child characteristics were obtained

through questionnaire, including current maternal birth weight and height, maternal age at child’s
INTEGRATIVE LITERATURE REVIEW 5

birth, child age and sex, birth weight, and infant feeding mode. Weight and body fat were

measured and variables were compared for proportions between women with and without

gestational diabetes. The authors found that children of GDM mothers had significantly higher

mean birth weight as well as a higher prevalence of obesity at age 9-11 compared with children

of non-GDM mothers.

In a systematic review and meta-analysis conducted by Miyazaki et al., (2018), the

authors searched observational studies on obesity and diabetes in offspring of mothers with

gestational diabetes, type 1 diabetes, and non-diabetic mothers born between January 1946 and

December 2016. Twenty observational studies were included which involved 26,509 children.

Data was independently extracted by researchers and pooled, then a meta-analysis was

performed. The authors found that offspring of mothers with GDM had significantly higher risk

of childhood obesity than offspring of non-diabetic mothers.

No Association Between Gestational Diabetes and Childhood Obesity

The results and findings of two of the research articles recognize that there is no

association between gestational diabetes and childhood obesity (Morgan et al., 2013; Pham et al.,

2013). Morgan et al. (2013) performed a population based electronic cohort study among

147,773 mother-child pairs identified using the National Community Child Health Database.

Offspring data was collected including weight at birth, 12 months, and 5 years then statistical

analysis was performed. Pham, Brubaker, Pruett, & Caughey (2013) conducted a retrospective

cohort study of women with and without gestational diabetes and their offspring. Maternal and

neonate data were collected from 2,644 mothers and their neonate or toddler offspring with the

use of electronic medical records. Statistical analysis was performed on the data provided.
INTEGRATIVE LITERATURE REVIEW 6

Discussion/Implications

The articles selected for review consisted of those that supported an association between

gestational diabetes and those that did not find an association. That being said, each article was

relevant to the PICO question, which was, “Are children of mothers diagnosed with gestational

diabetes during pregnancy at increased risk of developing childhood obesity than children of

mothers who were not diagnosed with gestational diabetes?” Four of the articles used statistical

analysis to interpret the quantitative data collected (Miyazaki et al., 2018; Zhao et al., 2016;

Morgan et al., 2013; Pham et al., 2013) while Hammound et al. (2018) used a random effects

model to estimate growth trajectory of offspring of mothers with gestational diabetes.

Recommendations for further research may include the use of multi-factorial parameters

surrounding maternal diabetes and offspring size.

Limitations

In conducting this integrative review, the researcher came across many limitations. The

researcher’s inexperience along with lack of familiarity about the process of an integrative

review is an influencing factor. The author also does not have the qualifications for providing a

reliable discussion on the subject being studied. Another limitation was that only five articles

were analyzed out of over 67,000 yielded before filters were applied. The minute time frame

filtered was also a limitation meaning that this was not a comprehensive review of all literature

on the topic.

Another limitation is associated with the process of selecting articles for review. The

collection process was restricted due to the fact that the researcher had difficulty obtaining full-

text articles. The selected articles had various sampling sizes based on the type of study. The

sample sizes were adequate based on the types of studies that were examined but there could
INTEGRATIVE LITERATURE REVIEW 7

have been bias introduced by the sampling strategy since it was not randomized. While a strength

of using a meta-analysis is that there is a larger sampling size, a limitation was that only

observational studies were used. Inevitable limitations occur when using routine data because of

the potential for misclassification bias.

Conclusions

The evidence compiled for this integrative review shows both evidence and absence of a

correlation between gestational diabetes and childhood obesity (Hammoud et al., 2018; Morgan

et al., 2013; Pham et al., 2013; Zhao et al., 2016; Miyazaki et al., 2018). By determining factors

that contribute to childhood obesity it may be possible to put interventions in place that can

minimize negative patient outcomes associated with gestational diabetes. While Morgan et al.

and Pham, Brubaker, Pruett, & Caughey (2013) found little evidence of an association between

gestational diabetes and childhood obesity, there is a considerable amount of literature that

supports the relationship (Hammoud et al., 2018; Miyazaki et al., 2018; Zhao et al., 2016). That

being said, goals should be set in place to help prevent the prevalence of gestational diabetes if it

means helping to reduce the risk of childhood obesity.

INTEGRATIVE LITERATURE REVIEW 8

References

Hammoud, N. M., Visser, G. A., van Rossem, L., Biesma, D. H., Wit, J. M., & de Valk, H. W.

(2018). Long-term BMI and growth profiles in offspring of women with gestational

diabetes. Diabetologia, doi:10.1007/s00125-018-4584-4

Miyazaki, C., Mori, R., Kawasaki, M., Ota, E., Ogawa, Y., Arata, N., & Kikuchi, T. (2018).

Obesity and abnormal glucose tolerance in offspring of diabetic mothers: A systematic

review and meta-analysis. Plos ONE, 13(1), 1-19. doi:10.1371/journal.pone.0190676

Morgan, K., Rahman, M., Atkinson, M., Zhou, S., Hill, R., Khanom, A., & ... Brophy, S. (2013).

Association of Diabetes in Pregnancy with Child Weight at Birth, Age 12 Months and 5

Years – A Population-Based Electronic Cohort Study. Plos ONE, 8(11), 1-8.

doi:10.1371/journal.pone.0079803

Pham, M. T., Brubaker, K., Pruett, K., & Caughey, A. B. (2013). Risk of childhood obesity in

the toddler offspring of mothers with gestational diabetes. Obstetrics & Gynecology,

121(5), 976-982. doi:10.1097/AOG.0b013e31828bf70d

Zhao, P., Liu, E., Qiao, Y., Katzmarzyk, P. T., Chaput, J., Fogelholm, M., & ... Hu, G. (2016).

Maternal gestational diabetes and childhood obesity at age 9-11: results of a multinational

study. Diabetologia, 59(11), 2339-2348. doi:10.1007/s00125-016-4062-9

Running head: INTEGRATIVE LITERATURE REVIEW
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
1
TABLE 1- ARTICLE EVALUATION
Zhao, P., Liu, E., Qiao, Y., Katzmarzyk, P. T., Chaput, J., Fogelholm, M., & ... Hu, G. (2016).
Maternal gestational diabetes and childhood obesity at age 9-11: results of a multinational
study. Diabetologia, 59(11), 2339-2348. doi:10.1007/s00125-016-4062-9
 Childhood obesity has increased in both developed as well as developing countries.
 Prenatal, perinatal, and postnatal factors could have an impact on childhood obesity.
 The aim of the study was to examine the association between maternal gestational diabetes
and childhood obesity at age 9-11 in 12 different countries.
 A multinational cross-sectional study of 4740 children aged 9-11 in 12 countries
 Maternal education, current maternal birth weight and height, maternal age at child’s birth,
child age and sex, birth weight, and infant feeding mode were collected from parents or
guardians by a demographic and family history questionnaire.
 Institutional Review Board at the Pennington Biomedical Research Center approved
overarching protocol
 Institutional/ethical review boards at each participating institution approved local protocols
 Written informed consent was obtained from parents or legal guardians
 Child assent was obtained
 BMI
 Waist circumference
 Body fat percentage
 Maternal gestational diabetes was diagnosed according to ADA or WHO criteria
 Height and waist circumference measured using standardized methods
 Weight and body fat were measured using a portable Tanita SC-240 Body Composition
Analyzer.
 Variables compared using a t test for means and a x^2 test for proportions between women
with and without gestational diabetes.
INTEGRATIVE LITERATURE REVIEW 2

 Multilevel linear regression models were used to estimate the association between maternal
gestational diabetes and childhood BMI, waist circumference, and body fat.
 Multilevel logistic regression models were used to estimate the association maternal
gestational diabetes and the odds of childhood obesity, central obesity, and high body fat.
 All statistical analyses were performed with SPSS for Windows, version 21.0 or SAS for
Windows, version 9.4

Findings/Discussion  Children of GDM mothers had significantly higher mean birth weight and significantly
higher prevalence of obesity, central obesity, and high body fat at age 9-11 compared with
children of non-GDM mothers.

Appraisal/Worth to practice  Maternal gestational diabetes was associated with increased odds of obesity and central
obesity in children 9-11 years.
 These associations were not fully independent of maternal BMI
INTEGRATIVE LITERATURE REVIEW 3

First Author Pham, M. T., Brubaker, K., Pruett, K., & Caughey, A. B. (2013). Risk of childhood obesity in
(Year)/Qualifications the toddler offspring of mothers with gestational diabetes. Obstetrics & Gynecology, 121(5),
976-982. doi:10.1097/AOG.0b013e31828bf70d

Background/Problem  There is evidence that supports the idea that intrauterine exposure to hyperglycemia out
Statement offspring at increased risk for long term adverse effects.
 There is also evidence that there is an association between childhood obesity and maternal
obesity, excessive weight gain during pregnancy, and large for gestational age (LGA)
newborns.

Conceptual/theoretical  A theoretical framework was not identified in the article.

Framework

Design/  Retrospective cohort study of women with and without gestational diabetes and their term
Method/Philosophical offspring.
Underpinnings  2,644 women met the criteria for participation. All participants had an initial exam including
a BMI calculation.
 Patients were screened for gestational diabetes with the 1 and 3 hour glucose tolerance test
between 24 and 28 weeks.
 Maternal and neonate data were collected as well as data for the toddler offspring with the
use of the electronic medical records 2-4 years after birth.
Sample/ Setting/Ethical  The Regional Prenatal Nursing Services database identified all patients with gestational
Considerations diabetes at Kaiser Performance Northern California Santa Clara.
 The study was approved with waiver of consent by the Kaiser Foundation Research Institute
Institutional Review Board.

Major Variables Studied (and  Body mass index for mother, neonate, then age 2-4 years.
their definition), if  Gestational weight gain
appropriate  Birth weight

Measurement Tool/Data  Gestational diabetes status differences were analyzed with Pearson X2 test and Student t test
Collection Method  Multivariable logistic regression models were used to predict toddler weight and obesity
factors.
INTEGRATIVE LITERATURE REVIEW 4

Data Analysis  Statistical analysis was performed using the SAS Statistical Analysis System for Windows
9.13 with P<0.05 being considered significant.

Findings/Discussion  There was no difference in the rate of overweight and obesity at age 2-4 years when
comparing offspring of women with gestational diabetes to women without gestational
diabetes.
 Obesity at age 2-4 was associated with maternal BMI and neonate LGA

Appraisal/Worth to practice  Of the 255 women with gestational diabetes and their offspring, there was no difference in
the rate of overweight and obesity at 2-4 years compared with toddlers of women without
gestational diabetes.
INTEGRATIVE LITERATURE REVIEW 5

First Author Pham, M. T., Brubaker, K., Pruett, K., & Caughey, A. B. (2013). Risk of childhood obesity in
(Year)/Qualifications the toddler offspring of mothers with gestational diabetes. Obstetrics & Gynecology, 121(5),
976-982. doi:10.1097/AOG.0b013e31828bf70d

Background/Problem  There is evidence that supports the idea that intrauterine exposure to hyperglycemia out
Statement offspring at increased risk for long term adverse effects.
 There is also evidence that there is an association between childhood obesity and maternal
obesity, excessive weight gain during pregnancy, and large for gestational age (LGA)
newborns.

Conceptual/theoretical  A theoretical framework was not identified in the article.

Framework

Design/  Retrospective cohort study of women with and without gestational diabetes and their term
Method/Philosophical offspring.
Underpinnings  2,644 women met the criteria for participation. All participants had an initial exam including
a BMI calculation.
 Patients were screened for gestational diabetes with the 1 and 3 hour glucose tolerance test
between 24 and 28 weeks.
 Maternal and neonate data were collected as well as data for the toddler offspring with the
use of the electronic medical records 2-4 years after birth.
Sample/ Setting/Ethical  The Regional Prenatal Nursing Services database identified all patients with gestational
Considerations diabetes at Kaiser Performance Northern California Santa Clara.
 The study was approved with waiver of consent by the Kaiser Foundation Research Institute
Institutional Review Board.

Major Variables Studied (and  Body mass index for mother, neonate, then age 2-4 years.
their definition), if  Gestational weight gain
appropriate  Birth weight

Measurement Tool/Data  Gestational diabetes status differences were analyzed with Pearson X2 test and Student t test
Collection Method  Multivariable logistic regression models were used to predict toddler weight and obesity
factors.
INTEGRATIVE LITERATURE REVIEW 6

Data Analysis  Statistical analysis was performed using the SAS Statistical Analysis System for Windows
9.13 with P<0.05 being considered significant.

Findings/Discussion  There was no difference in the rate of overweight and obesity at age 2-4 years when
comparing offspring of women with gestational diabetes to women without gestational
diabetes.
 Obesity at age 2-4 was associated with maternal BMI and neonate LGA

Appraisal/Worth to practice  Of the 255 women with gestational diabetes and their offspring, there was no difference in
the rate of overweight and obesity at 2-4 years compared with toddlers of women without
gestational diabetes.
INTEGRATIVE LITERATURE REVIEW
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if
appropriate
Measurement Tool/Data
Collection Method
7
Morgan, K., Rahman, M., Atkinson, M., Zhou, S., Hill, R., Khanom, A., & ... Brophy, S.
(2013). Association of Diabetes in Pregnancy with Child Weight at Birth, Age 12 Months and 5
Years – A Population-Based Electronic Cohort Study. Plos ONE, 8(11), 1-8.
doi:10.1371/journal.pone.0079803
 There seems to be a link between diabetes during pregnancy and childhood obesity
 The authors analyze health data to identify an association between existing diabetes,
gestational diabetes and maternal diabetes developed post pregnancy and how those factors
effect child weight at birth, age 12 months, and 5 years.
 A theoretical framework was not identified in the article.
 A population based electronic cohort study
 Mother-child pairs were identified using the National Community Child Health Database
 The sample size was 147,773 mother-child pairs
 Ethical considerations were addressed but participant consent was not obtained due to the
nature of the study design, which was the use of archival data.
 Pre-pregnancy BMI
 Birth weight of offspring
 Gestational age
 Small for gestational age
 Large for gestational age
 >90th percentile by age 12 months
 >90th percentiel at age 60 months
 Compared this data for women without diabetes, existing diabetes gestational diabetes, and
diabetes developed post pregnancy.
 Data collection methods include the use of the National Community Child Health Database
(NCCHD) and Secure Anonymised Information Linkage (SAIL) databank.
INTEGRATIVE LITERATURE REVIEW 8

 Offspring data included weight measures at birth, 12 months, and 5 years.

Data Analysis  Statistical analysis was performed using STATA version 12

 Differences in baseline characteristics as they are related to maternal diabetes status were
analyzed using t tests and X2 tests for continuous and categorical variables.
 Binary logistic regression was used to calculate the odds ratios for small or large offspring at
birth according to maternal diabetes status.

Findings/Discussion  There was evidence found to support an association between diabetes in pregnancy and
larger birth weight
 Mothers with existing diabetes were less likely to have a large infant at 12 months age.

Appraisal/Worth to practice  Evidence was found to support diabetes in pregnancy is associated with larger birth weight.
 There is limited evidence that diabetes during pregnancy leads to increased weight of the
offspring at 5 years.
 The influence seen at birth does not seem to last into childhood
INTEGRATIVE LITERATURE REVIEW
First Author
(Year)/Qualifications
Background/Problem
Statement
Conceptual/theoretical
Framework
Design/
Method/Philosophical
Underpinnings
Sample/ Setting/Ethical
Considerations
Major Variables Studied (and
their definition), if
appropriate
Measurement Tool/Data
Collection Method
Data Analysis
9
Miyazaki, C., Mori, R., Kawasaki, M., Ota, E., Ogawa, Y., Arata, N., & Kikuchi, T. (2018).
Obesity and abnormal glucose tolerance in offspring of diabetic mothers: A systematic review
and meta-analysis. Plos ONE, 13(1), 1-19. doi:10.1371/journal.pone.0190676
 A public health issue includes a rising prevalence of childhood obesity and type 2 diabetes
 The authors investigate not only an association between gestational diabetes with obesity but
also at what age abnormal glucose intolerance occurs in the offspring.
 A theoretical framework was not identified in the article.
 MEDLINE and EMBASE was searched for observational studies on obesity and diabetes in
offspring of mothers with gestational diabetes, type 1 diabetes, and non-diabetic mothers
born between January 1946 and December 2016.
 A fixed effect meta-analysis for all studies except when heterogeneity was detected.
 Quality of studies were evaluated using the Risk of Bias Assessment Tool for
Nonrandomized Studies (RoBANS).
 20 observational studies were included which involved 26,509 children.
 Exposure to maternal diabetes, including gestational diabetes, type 1 and type 2 diabetes.
 BMI
 Fasting plasma glucose and 2 hour plasma glucose
 Eligible titles and abstracts were screened and full-text articles of relevant studies were
obtained.
 Data was independently extracted by researchers
 Age of offspring was divided into 4 categories: 2-6 years old, 7-9 years old, 10-15 years old,
16-19 years old
 Data was pooled and meta-analysis was performed.
 Odds ratios were calculated using a fixed-effects model
INTEGRATIVE LITERATURE REVIEW 10

 Mean differences with 95% confidence interval was used for continuous data
 All statistical analyses were performed using Review Manager version 5 software
 Quality of evidence was evaluated with the Grading of Recommendations Assessment,
Development, and Evaluation (GRADE).

Findings/Discussion  20 studies were included in the systematic review

 Offspring of mothers with type 1 diabetes had higher BMI z-score from prepubertal to
adolescent
 Offspring of mothers with gestational diabetes had higher 2 hour plasma glucose from
prepubertal to adolescence

Appraisal/Worth to practice  Offspring of mothers with gestational diabetes had significantly higher risk of childhood
obesity or overweight than offspring of non-diabetic mothers.