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Integrative Review
Integrative Review
An Integrative Review
Caroline M. Stewart
Abstract
The purpose of this integrative review is to evaluate current literature pertaining to the effects of
concern globally, and determining predisposing factors for this issue could be the key to
reducing rates across the board. Due to GDM’s influence on large birth weight, researchers are
interested to determine if that influence carries on into childhood as well, potentially causing
obesity. EBSCO was utilized in searching for articles for this review. After placing limits, the
search yielded 7,480 articles. Five of these articles that best represented the aim of the PICOT
question were chosen by the researcher. No correlation was found to exist between GDM status
and childhood obesity in offspring. A correlation was, however, found between maternal pre-
pregnancy body mass index (BMI) and future occurrences of childhood obesity. Several
limitations to this review must be mentioned including the review only examining five articles
and the researcher having little experience completing integrative reviews. Limitations of the
studies reviewed included lack of diversity in the selected sample and collecting data in ways
that allowed for bias. The findings discussed in this review should encourage healthcare
professionals to educate women about the importance of maintaining a healthy body weight and
the potential effects related to uncontrolled GDM. Further research should include larger sample
sizes, longer duration, and additional follow-up studies to determine long-term effects.
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An Integrative Review
Childhood obesity is a growing concern both in the United States and abroad.
Recognizing risk and predisposing factors is the first step in decreasing and preventing this
growing epidemic. It is suspected that exposure to high levels of glucose in utero may place
offspring at a greater risk for developing obesity during childhood. The aim of this integrative
review is to collate literature pertaining to the researcher’s PICO question, are children (ages 2-
11) born to mothers with gestational diabetes at increased risk for childhood obesity compared
with children born to mothers without gestational diabetes? Until recent years, research
regarding this topic has been limited. However, researchers are becoming increasingly interested
in the potential link between gestational diabetes and childhood obesity, therefore more studies
are being conducted. What is currently known about this topic is that gestational diabetes has a
direct effect on birth weight and mothers with GDM often produce newborns that are large for
gestational age (LGA). The gap in knowledge and research exists due to the fact that it is
unknown if GDM influences weight and BMI during childhood as it does at time of birth. Fully
understanding if there is a correlation between GDM and childhood obesity could potentially
provide the knowledge necessary to decrease the prevalence of this growing problem.
This integrative review is based on five articles. EBSCO is the only search engine that
was used in searching for these articles. Search word used in the search included, ‘gestational
diabetes’, ‘childhood obesity’, ‘diabetes’, ‘childhood BMI’, and ‘pregnancy’. A search via
EBSCO resulted in 7,480 articles from which the final five were chosen.
In an effort to narrow the search, a limit was set to only show articles published between
2013 and 2018. Another filter was placed for the search to only yield peer reviewed articles with
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a full text available. After searching under these parameters, the researcher was able to locate
five quantitative studies that relate to the PICO question. Articles were excluded if they were
published more than five years ago, not peer reviewed, or did not contain a research study
Finding/Results
The findings and results of the research do not necessarily prove that there is a correlation
between GDM and childhood obesity (Landon et al., 2015; Morgan et al., 2013; Pham, Brubaker,
Pruett & Caughey, 2013; Zhao et al. 2016; Zhu et al. 2016). The review of these findings and
results is structured by the following themes: maternal GDM status, levels of maternal glycemia
In three quantitative studies, researchers focused on maternal GDM status and how it
related to childhood obesity (Morgan et al., 2013; Pham et al., 2013; Zhao et al., 2016). With this
approach, researchers simply wanted to know if the mother was diagnosed with GDM or not. No
specific glucose levels were factored in to determine the severity of each individual’s GDM. In
the population based electronic cohort study by Morgan et al. (2013), 147,773 mother-child pairs
from electronic medical records (EMR). The data collected consisted of maternal diabetes status
and offspring weight at birth and ages 1 and 5 years. The purpose of this study was to determine
if offspring weight is affected by GDM. Logistic regression models were used to examine
relationships between maternal diabetes status and offspring size. This data was adjusted to allow
for variations in maternal pre-pregnancy weight, age, and smoking status. Evidence was found
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linking diabetes in pregnancy to large birth weight, above the 90th percentile. However, limited
evidence was found linking diabetes in pregnancy with large weight at 1 and 5 years of age.
Similarly, the study by Pham et al. (2013), aimed to estimate whether children, aged 2-4
years, of mothers with GDM are at risk for childhood obesity. This retrospective cohort study
consisted of 2,644 women (459 in the GMD group and 2,185 in the non GDM group). This
sample greatly decreased throughout the study because researchers were only able to collect BMI
data from 255 of the 459 GDM woman toddler pairs and 1,838 of the 2,185 non GDM pairs at
the 2-4 year mark. Each participant underwent an initial exam in early pregnancy (~8 weeks
gestation) in which weight, height, and demographics were collected to calculate a BMI which
was the primary factor measured in this study. Gestational weight gain was determined by the
final data collected at 37 weeks gestation. Glucose tolerance tests were performed between 24
and 28 weeks of gestation to determine maternal GDM status. Toddler offspring BMI data was
collected 2-4 years after birth via EMR and BMIs greater than the 85th percentile were defined as
overweight and obese. Pearson [chi]2 test was used to determine categorical variables of
differences in GDM status, and Student t test was used for continuous variables. The [chi]2 test
was also used to determine differences in rates of GDM, LGA, and toddler overweight or obesity
by race or ethnicity. Multivariable logistic regression models were used to predict toddler
overweight and obesity rates and used maternal pre-pregnancy BMI as a risk factor. The study
showed that GDM was not associated with increased risk of toddler overweight and obese BMI.
However, evidence was present that related pre-pregnancy overweight and obese BMI to that of
The multinational cross-sectional study, by Zhao et al. (2016), aimed to determine the
association between maternal GDM and childhood obesity at age 9-11 years in 12 countries. This
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study consisted of 4,740 children between the ages of 9 and 11 years. Maternal GDM status was
determined by the American Diabetes Association (ADA) or World Health Organization (WHO)
criteria. Demographics and family health history including maternal education, current maternal
BMI, maternal age at child’s birth, child age, child sex, birthweight, infant feeding mode,
gestational age and number of younger siblings were collected upon initiation of the study by a
questionnaire given to parents or guardians. Maternal GDM status was self-reported by parents
or guardians on the questionnaire. A food frequency questionnaire (FFQ) was administered to all
participants and asked about their usual consumption of 23 food categories. The FFQ allowed for
response categories including: never, less than or once per week, once per week, 2-4 days per
week, once a day every day, and more than once a day. This questionnaire was used primarily to
determine whether participants represented an unhealthy or healthy diet pattern. Physical exams
were conducted on each participant to determine height, waist circumference, weight, body fat
percentage, and maternal and childhood BMI. Multilevel linear regression models were used to
determine association between GDM and childhood BMI, waist circumference and body fat
percentage. In this study, children of GDM mothers had significantly higher mean values for
BMI, waist circumference, and body fat percentage than children of non-GDM mothers.
However, it is unclear as to whether or not these results are influenced by current maternal BMI.
Further research is needed to determine whether GDM status alone influenced childhood obesity
in this study or if current maternal BMI and other environmental factors surrounding the children
not there is a correlation between fasting plasma glucose (FPG) levels during pregnancy and
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offspring growth and risk of overweight and obese BMI through age 7 years. This study was a
follow-up study based on data from the Danish National Birth Cohort (DNBC), a longitudinal
nationwide study that included 101,042 pregnancies. The original data from the DNBC consisted
of sociodemographic, perinatal, and medical factors and was collected from 4 computer-assisted
telephone interviews at gestational weeks 12 and 30 and postpartum months 6 and 18. When the
children of these mothers were 7 years old, this follow-up study was conducted by sending
questionnaires online or by mail to the parents. The questionnaires asked about the child’s health
and development, including weight and height as to calculate BMI. Maternal FPG
concentrations during pregnancy were positively associated with large offspring birth size and
Treatment of GDM
obesity. In this study, 500 participants underwent a physical exam which included height,
weight, blood pressure, and waist circumference. These participants were offspring of women
who participated in a Eunice Kennedy Shriver National Institute of Child Health and Human
Development Maternal-Fetal Medicine Units (MFMU) Network randomized clinical trial for
mild GDM. Mothers of the child participants were given a questionnaire concerning
demographic information, breastfeeding history, child health, diet, and physical activity.
Statistical analysis was completed using SAS statistical software (SAS Institute, Cary, NC).
Tests were two-tailed and P<0.05 was used to define statistical significance. At conclusion of
this study, no difference was observed in obesity rate for offspring of mothers who were treated
While the results of two of the five studies discussed in this review differ slightly from
the remaining three, the consensus is that there is little to no correlation between GDM and
childhood obesity. The two articles that resulted in GDM having a correlation with childhood
obesity examined other factors such as maternal BMI that could have potentially skewed results.
Given that the majority of research proved no relationship between GDM and childhood obesity,
the PICOT question set by the researcher is supported in this review. GDM does not put
The study by Landon et al. (2015), provided evidence that uncontrolled GDM does in fact
lead to negative outcomes in childhood such as overweight/obese BMI. The other four studies
only examined mothers with controlled GDM and their offspring’s outcomes, but this particular
study showed that there is definitely a difference in outcomes between controlled and
uncontrolled GDM.
Possessing the knowledge that controlled GDM does not have a significant correlation
with increased risk of childhood obesity when controlled appropriately allows healthcare
professionals to debunk this myth as well as to educate pregnant women diagnosed with GDM of
just how important it is to maintain tight glycemic control during pregnancy. The secondary aim
of the study by Pham et al. (2013), was to examine the potential correlation between maternal
BMI and childhood obesity. The data provided within that study proved that there is a
relationship between high maternal BMI and childhood obesity rates. Knowing this allows
Pham et al. (2013) discusses the possibility of GDM management being a modifiable risk
factor for childhood obesity. Subsequently, the researchers recommend further research to
determine whether interventions for GDM and those aimed at decreasing maternal BMI could
help to reduce childhood obesity rates. Similarly, Morgan et al. (2013) addressed how their
results warrant the need for further research to include multi-factorial parameters surrounding
maternal diabetes and offspring size. From a different perspective, Zhu et al. (2016), determined
that further research generalized to other racial and ethnic groups at high risk of GDM may be
warranted to validate their study due to the fact that their study population was composed of only
population for future studies. The authors also recommend longer studies with follow-up
opportunities through adolescence and adulthood of the offspring. Landon et al. (2015) also
discuss the need for larger follow-up studies in order to provide evidence of how the cycle of
Limitations
Major limitations of this integrative review include the fact that it only consists of five
articles pertaining to the PICOT question at hand. A broader base of research would be beneficial
for a more diverse view on the topic of how GDM relates to childhood obesity. It should also be
mentioned that a significant amount of the articles populated through the search on EBSCO were
outside of the five year limit set for this assignment. This greatly decreased the amount of
research available for the researcher to present within this integrative review. This review was
brief as it only contained five studies, therefore it did not exhaust all potential contributing
factors of childhood obesity and they may or may not relate to GDM. The researcher compiling
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information for this review does not have a significant amount of experience in completing an
integrative review.
Each of the five studies presented in this review suffered from their own individual
limitations. Zhao et al. (2016) determined that one limitation of their study was simply the fact
that it is a cross-sectional study. Zhao et al. (2016) said about this limitation, “Thus, we could not
make cause-and-effect inferences.”(p. 2347) A third limitation of the study by Zhao et al. (2016),
is that maternal GDM status, current maternal body weight and height, infant feeding mode,
gestational age and child’s birth weight was self-reported by parents or guardians. This allowed
for potential bias in results. Possible the most influential limitation of this study is that maternal
GDM was diagnosed under different standards at each different site which may have greatly
skewed results.
Landon et al. (2015) discussed using BMI as the primary measure of obesity as being one
of the primary limitations of their study. Subsequently, the researchers discussed how other
measures of body composition, such as DEXA or air densitometry may have been a more
accurate way of determining obesity status within the study. Lastly, Landon et al. (2015),
discussed the fact that the participants of this study were women with only mild GDM. The
researchers went on to say that the study could have been improved by including women with
varying levels of GDM so as to demonstrate a more diverse treatment approach and the effect it
The study by Pham et al. (2013), had possibly the most devastating limitation of the five
within this review. During the study, the criteria by which GDM is diagnosed was changed from
the National Diabetes Data Group to that of Carpenter and Coustan. Another limitation of this
study is that the population is limited to only one facility. In that facility, Asian and South Asian
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population. Being that the study was limited to one facility, it also included far more individuals
who are insured with moderate to high socioeconomic status than it did uninsured individuals
Morgan et al. (2013) suffered most of their limitations due to the method of data
collection. Patients’ health information was retrieved from EMR which did not allow for
explanation of any results or findings within the patient history other than what was provided in
documentation. The main issue with this is that the group labeled ‘diabetes developed post
pregnancy’ may have also included some women who truly had GDM but were misdiagnosed
Zhu et al. (2016) suffered a limitation within their study pertaining to the method of data
collection. Due to the fact that childhood weight and height data were obtained via a
Conclusion
Within this integrative review, the researcher was able to compile information from five
studies that all examined whether or not there is a correlation between GDM and childhood
obesity. The collective findings lead researchers to believe that there is no relationship between
maternal GDM status and subsequent childhood obesity in offspring. Some findings of the
studies reviewed suggest that pre-pregnancy maternal BMI as well as other environmental
factors could predispose children to obesity. These results directly relate to the PICOT question
by determining that there is no known correlation between GDM and childhood obesity at this
time.
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References
Landon, M. B., Rice, M. M., Varner, M. W., Casey, B. M., Reddy, U. M., Wapner, R. J., . . .
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
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,
Zhao, P., Liu, E., Qiao, Y., Katzmarzyk, P. T., Chaput, J., Fogelholm, M., . . . Hu, G. (2016).
Zhu, Y., Olsen, S. F., Mendola, P., Yeung, E. H., Vaag, A., Bowers, K., . . . Zhang, C. (2016).
Growth and obesity through the first 7y of life in association with levels of maternal
Conceptual/theoretical Researchers wanted to determine the risk of obesity in toddler offspring (aged 2-4
Framework years) of mothers who had gestational diabetes mellitus (GDM).
Design/ Quantitative
Method/Philosophical Retrospective cohort study
Underpinnings Each patient had an initial exam consisting of weight, height, and demographics.
Data collected was used to determine patient BMI which was the primary factor
measured.
Gestational weight gain was determined by the final data collected at 37 weeks
gestation.
1-hour glucose tolerance tests were conducted between 24 and 28 weeks of gestation
Patients who failed the 1-hour moved on to have the 3-hour test
Toddler offspring BMI data was collected via EMR and BMI’s greater than the 85th
percentile were defined as overweight and obese.
Sample/ 2,644 women met the study cohort selection criteria (459 women in GDM group and
Setting/Ethical 2,185 in the non GDM group)
Considerations Researchers were only able to collect BMI data for 255 of the 459 GDM woman
toddler pairs at the 2-4 year mark and 1,838 of the 2,185 in the non GDM group
Kaiser Permanente Northern California in Santa Clara medical center (tertiary care
teaching hospital with outpatient clinics)
Study was approved with waiver of consent by the Kaiser Foundation Research
Institute Institutional Review Board
Major Variables GDM group – mothers with gestational diabetes mellitus
Studied (and their Non GDM group – mothers without gestational diabetes mellitus
definition), if
appropriate
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Measurement Data was collected via physical exams at different points in the study
Tool/Data Collection Height and weight of expectant mothers was collected to determine BMI at 8 weeks
Method gestation and again at 37 weeks gestation to determine gestational weight gain.
BMI was collected for toddler offspring via EMR at 2-4 years of age.
Data Analysis Statistical analysis preformed using the SAS Statistical Analysis System for Windows
9.13, and P<.05 was considered significant.
Differences in GDM status were determined with Pearson [chi]2 test for categorical
variables and Student t test for continuous variables.
Findings/Discussion GDM was not associated with increased risk of toddler overweight and obesity.
Toddler overweight and obesity is, however, related to pre-pregnancy overweight and
obesity of the mother.
Appraisal/Worth to These findings can be implemented into practice by educating expectant mothers
practice about maintaining a healthy body weight to prevent putting future offspring at risk for
obesity.
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First Author Zhu (2016) – Division of Intramural Population Health Research, Eunice Kennedy Shriver
(Year)/Qualifications National Institute of Child Health and Human Development, NIH Rockville, MD
Background/Problem The long-term effects of childhood obesity warrants identification of early life risk
Statement factors that may predispose individuals to this condition
Gestational diabetes is a common metabolic disorder in pregnant women that is
theorized to have a connection to childhood obesity.
Conceptual/theoretical Researchers wanted to find out if there was a correlation between fasting plasma
Framework glucose (FPG) concentrations during pregnancy and offspring growth and risk of
overweight/obesity through age 7 years.
Design/ Quantitative
Method/Philosophical FPG was taken at 28 weeks gestation from medical records of patients within the
Underpinnings study
Offspring’s ponderal index was derived from birth weight and length; age- and sex-
specific BMI scores at 5 months, 12 months, and 7 years.
Relations between FPG and offspring obesity rates were then assessed
Form interviews were collected at 12 and 30 weeks of gestation.
Sample/ Setting/Ethical 661 pregnant women with gestational diabetes took part in this study
Considerations Data from the Danish National Birth Cohort (DNBC) which is a longitudinal
nationwide study including 101,042 pregnancies.
Lack of follow up by participants led there to be only 405, 397, and 351 mother-
offspring pairs with available data on offspring measures at the 5 month, 12
month, and 7 year follow up, respectively.
No ethical considerations listed.
Major Variables Studied Women with GDM
(and their definition), if Covariates included: parity, socioeconomic status, pre-pregnancy BMI, and
appropriate smoking during pregnancy.
Measurement Tool/Data Data was collected from EMR and form interviews
Collection Method
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Data Analysis
Statistical analyses were conducted with SAS version 9.4
Two-tailed P values <0.05 were considered statistically significant
Findings/Discussion At 7 years of age, high maternal FPG concentrations were significantly associated
with increased BMI
Maternal FPG concentrations during pregnancy were positively associated with
offspring birth size and overweight/obesity risk at 7 years of age.
Appraisal/Worth to
practice Knowing that increase FPG concentrations are associated with childhood obesity
allows medical professionals to be proactive in educating and helping pregnant
women to manage their concentration and maintain tighter glycemic control to
decrease risk of childhood obesity in their offspring.
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First Author Morgan (2013) – College of Medicine, Swansea University, Swansea, Wales, United
(Year)/Qualifications Kingdom
Background/Problem
Statement Gestational diabetes is linked to complications in pregnancy and is recognized as
a modifier of growth and development in the fetus
Conceptual/theoretical Researchers wanted to see if the influence that GDM has on the fetus extends to
Framework childhood (1-5 years).
Design/ Quantitative
Method/Philosophical Population based electronic cohort study
Underpinnings Maternal diabetes status was determined through EMR
Offspring weight at birth and ages 1 and 5 years was also determined via EMR
Logistic regression models were used to obtain odds ratios to describe the
association between maternal diabetes status and offspring size.
Sample/ Setting/Ethical 147,773 mother-child pairs
Considerations All data was collected from the Health Information Research Unit Swansea
University, UK
Major Variables Studied Women without diabetes
(and their definition), if Women with pre-pregnancy diabetes
appropriate Women with gestational diabetes
Women who developed diabetes post pregnancy
Measurement Tool/Data
Collection Method Healthcare data for each participant was routinely collected through electronic
medical records
Data Analysis All statistical analyses were performed using STATA version 12.
Binary logistic regression was used to calculate odds ratios
Findings/Discussion Evidence was found linking diabetes in pregnancy to larger birth weight
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There is limited evidence that diabetes in pregnancy leads to a large weight of the
child at 5 years
More research is necessary to determine parameters surrounding maternal
diabetes and offspring size.
Appraisal/Worth to These findings can be implemented into practice by educating expectant mothers
practice about maintaining a healthy body weight to prevent putting future offspring at risk
for obesity.
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First Author Zhao (2016) – Tianjin Women’s and Children’s Health Center, Tianjin, China
(Year)/Qualifications
Background/Problem Childhood obesity is rapidly increasing in both developed and developing
Statement countries.
Various environmental factors are thought to be to blame for this
Some studies show that there may be an association between GDM and
childhood obesity
Conceptual/theoretical To examine the association between maternal gestational diabetes mellitus (GDM)
Framework and childhood obesity at age 9-11 years in 12 countries around the world.
Design/ Quantitative
Method/Philosophical Multinational cross-sectional study
Underpinnings Study took place across 12 countries
Researchers identified mothers of children 9-11 years of age and assessed the
mother and child’s BMI and other weight related factors.
Mothers were asked about history of GDM with the pregnancy of the child.
A food frequency questionnaire was dispersed to participants
Measurements were taken of mother and child for BMI, height, weight, waist
circumference, and body fat percentage
Sample/ Setting/Ethical Institutional review board at the Pennington Biomedical Research Center
Considerations approved the research protocol, and each individual review board at the different
facilities approved local protocol.
Written informed consent was obtained from parents or legal guardians, and child
assent was also obtained
Major Variables Studied GDM
(and their definition), if Non-GDM
appropriate
Measurement Tool/Data A survey was dispersed to evaluate food frequency and habits
Collection Method Measurements were taken from each participant
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Data Analysis Analyses were performed with SPSS for Windows version 21.0 or SAS for
Windows, version 9.4.
Multilevel linear regression models were used to estimate the association between
maternal GDM and z scores of childhood BMI, waist circumference, and body fat.
Findings/Discussion After adjusting for all confounders of the study, children of GDM mothers had
significantly higher mean values for BMI, waist circumference, and body fat
percentage than children of non-GDM mothers.
These results were not fully independent of maternal BMI
Appraisal/Worth to This study proves that GDM does have an impact on the prevalence of childhood
practice obesity, but that impact may also be related to high maternal BMI.
More education is needed for parents about maintaining a healthy weight
themselves so as to encourage a healthy lifestyle and weight in their children.
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First Author Landon (2015) – Department of Obstetrics and Gynecology, The Ohio State University
(Year)/Qualifications College of Medicine, Columbus, OH
Background/Problem Gestation diabetes is increasing in prevalence as is childhood obesity
Statement Treatment of gestational diabetes could be linked to better outcomes later in life
for the offspring of mothers with GDM.
Conceptual/theoretical Researchers want to see if there truly is a relationship between treatment of GDM
Framework and decreased incidence of lifelong complications in offspring such as childhood
obesity.
Design/ Quantitative
Method/Philosophical Follow-up study of participants from a Eunice Kennedy Shriver National Institute of
Underpinnings Child Health and Human Development Maternal-Fetal Medicine Units (MFMU)
Network randomized clinical trial for mild GDM.
Mild GDM was defined as fasting glucose level <95 mg/dL and two of three timed
measurements that exceeded established thresholds.
“Follow-up study of the offspring from a randomized treatment trial for mild GDM to
determine whether treatment influences child health outcomes.”
Sample/ Setting/Ethical Eunice Kennedy Shriver National Institute of Child Health and Human
Considerations Development MFMU.
500 participants enrolled
No ethical considerations
Major Variables Studied Offspring of mothers treated for GDM
(and their definition), if Offspring of mothers not treated for GDM
appropriate Waist circumference
Fasting plasma glucose
Blood pressure
Measurement Tool/Data
Collection Method Original health records found in EMR
Physical exams of participants
Data Analysis
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SAS statistical software (SAS Institute, Cary, NC) was used for the analyses.
Tests were two-tailed and P<0.05 was used to define statistical significance
No imputation for missing data was performed
Findings/Discussion No difference was observed in obesity rate for offspring of mothers who were
treated for GDM versus mothers who were not treated.
Appraisal/Worth to This knowledge allows for a better understanding of the predisposing factors of
practice childhood obesity as well as the effects of GDM treatment on maternal offspring.