Maternal obesity and offspring body composition by indirect methods: a systematic review and meta-analysis

Castillo-Laura, Helen; Santos, Iná S.; Quadros, Lenice C. M.; Matijasevich, Alicia

doi:10.1590/0102-311X00159914

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REVIEW • Cad. Saúde Pública 31 (10) • Oct 2015 • https://doi.org/10.1590/0102-311X00159914 copy

Maternal obesity and offspring body composition by indirect methods: a systematic review and meta-analysis

Obesidad maternal y composición corporal de los hijos por métodos indirectos: revisión sistemática y metaanálisis

Obesidade materna e composição corporal dos filhos por métodos indiretos: revisão sistemática e meta-análises

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

This study reviewed the evidence that assessed the association between maternal pre-pregnancy body mass index (BMI) and/or gestational weight gain and offspring body composition in childhood. A systematic review was conducted. Cohort studies, case-control studies and randomized controlled trials measuring offspring body composition by indirect methods were included. Meta-analyses of the effect of pre-pregnancy BMI on offspring fat-free mass, body fat percent, and fat mass were conducted through random-effects models. 20 studies were included, most of which reported a positive association of pre-pregnancy BMI with offspring body fat. Standardized mean differences in body fat percent, fat mass and fat-free mass between infants of women with normal pre-pregnancy BMI and those of overweight/obese women were 0.31 percent points (95%CI: 0.19; 0.42), 0.38kg (95%CI: 0.26; 0.50), and 0.18kg (95%CI: -0.07; 0.42), respectively. Evidence so far suggests that pre-pregnancy maternal overweight is associated with higher offspring adiposity.

Obesity; Pregnancy; Body Composition; Adiposity

Author (city, country)	Design/N/Score Downs & Black ²⁶	Inclusion and exclusion criteria	Maternal exposure	Indirect method /Outcome age measurement	Adjustment variables
Berkowitz et al. ³⁴ (Philadelphia, USA)	Prospective cohort N = 78 Score = 14	Inclusion: maternal age > 18 years old, caucasian. Offspring healthy, uncomplicated full-term births. Exclusion: maternal gestational diabetes. Offspring: gestational age < 36 or > 42 weeks, low or high birth weight for gestational age	Maternal pre-pregnancy BMI	DEXA, at 6 years of age	Maternal: family income, obesity risk. Offspring: gender, weight at age two
Burdette et al. ³⁵ (Cincinnati, USA)	Prospective cohort N = 313 Score = 15	Inclusion: father and mother of same race. Offspring: full-term birth, no chronic diseases	Maternal pre-pregnancy BMI	DEXA, at 5 years of age	Maternal: race, age, education, smoking during pregnancy, marital status, family income, nutrition program. Offspring: gender, lean mass, birth weight, breastfeeding, overfeeding
Sewell et al. ²⁹ (Cleveland, USA)	Prospective cohort N = 220 Score = 15	Inclusion: pregnant women with normal glucose tolerance, singleton pregnancy. Exclusion: maternally or gestational diabetes mellitus. Offspring: birth weight < 2,000g, congenital anomalies	Maternal pre-pregnancy BMI	TOBEC, at 72 hours after birth	None
Sewell et al. ²⁹ (Cleveland, USA)	Prospective cohort N = 220 Score = 15		Gestational weight gain	TOBEC, at 72 hours after birth	Maternal: glucose, smoking during pregnancy. Offspring: gestational age, gender
Gale et al. ²⁸ (Southampton, UK)	Prospective cohort N = 216 Score = 18	Inclusion: maternal: caucasian, age ≥ 16 years, singleton pregnancy. Exclusion: maternal gestational diabetes, hormonal therapy for pregnancy. Offspring: gestational age < 17 weeks	Maternal pre-pregnancy BMI	DEXA, at 9 years of age	Maternal: height, gestational weight gain, smoking during pregnancy. Offspring: height, birth weight, breastfeeding, conditional weight gain
Gale et al. ²⁸ (Southampton, UK)	Prospective cohort N = 216 Score = 18		Gestational weight gain	DEXA, at 9 years of age	Maternal: height, smoking during pregnancy, pre-pregnancy BMI. Offspring: height, birth weight, breastfeeding, conditional weight gain
Lawlor et al. ³⁸ (Avon, UK)	Prospective cohort N = 3,263 Score = 17	Inclusion: singleton pregnancy	Maternal pre-pregnancy BMI	DEXA, at 9-11 years of age	Height and height squared at time of DEXA assessment, gender, age, family social class, parental education, parity, parental smoking at time of pregnancy, offspring pubertal status at time of DEXA assessment, breastfeeding
Hull et al. ⁵ (Oklahoma City, USA)	Prospective cohort N = 72 Score = 15	Inclusion: maternal: age at delivery 18-45 years old. Offspring: healthy, full-term birth. Exclusion: maternal smoking and excessive alcohol consumption during pregnancy, diabetes type 1, 2 or gestational diabetes. Offspring: congenital anomalies	Maternal pre-pregnancy BMI	ADP, at first 35 days of age	Age of children at time of visit
Crozier et al. ⁴² (Southampton, UK)	Prospective cohort N = 948 Score = 15		Gestational weight gain	ADP, at birth, age 4 years, age 6 years of age	Maternal: pre-pregnancy BMI, smoking during pregnancy, age, height, parity, education. Offspring: birth weight, height, duration of breastfeeding, gender, age at time of assessment
Hull et al. ⁶ (New York, USA)	Prospective cohort N = 306 Score = 15	Inclusion: healthy, full-term birth, singleton pregnancy. Exclusion: maternal diabetes, hypertension or pre-eclampsia. Offspring: congenital anomalies, admission to ICU	Maternal pre- pregnancy BMI	ADP, at 24-48 hours after birth	None
Hull et al. ⁶ (New York, USA)	Prospective cohort N = 306 Score = 15		Gestational weight gain	ADP, at 24-48 hours after birth	Maternal: skin color/race, age. Offspring: gender, gestational age, age at the time of the assessment
Au et al. ²⁷ (Sydney, Australia)	Retrospective cohort N = 599 Score = 15	Inclusion: full-term birth, living within the geographical area of the health service. Exclusion: maternal gestational diabetes. Offspring: congenital anomalies or admission to ICU	Maternal pre- pregnancy BMI	ADP, at 48 hours after birth	Maternal: ethnicity, parity, hypertension, gestational weight gain, gestational diabetes mellitus status. Offspring: gender, gestational age
Josefson et al. ⁴¹ (Chicago, USA)	Prospective cohort N = 38 Score = 13	Inclusion: maternal normal diabetes screening test in normal-weight	Gestational weight gain	ADP, at 72 hours after birth	None
Henriksson et al. ⁴⁴ (Linkoping, Sweden)	Prospective cohort N = 312 Score = 15	Inclusion: healthy offspring, singleton, full-term. Exclusion: Maternal: pre-eclampsia, lack of pregnancy weight, serious disease.	Gestational weight gain	ADP, at 2 to 11 days of age	Maternal: smoking habits, parity, educational level. Offspring: height
Carlsen et al. ³² (Copenhagen, Denmark)	Randomized controlled trial N = 311 Score = 24	Inclusion: offspring: singleton, full-term. Exclusion: maternal; chronic disease, pre-eclampsia. Offspring: congenital malformations, admission to ICU	Maternal pre-pregnancy BMI	DEXA, within 48 hours after at birth	Maternal: age, education level, smoking habits
Estampador et al. ⁴³ (Vasterbotten, Sweden)	Prospective cohort N = 33 Score = 23	Inclusion: singleton pregnancy	Rate of gestational weight gain	ADP, at 4 months of age	None
Tanvig et al. ³⁹ (Odense, Denmark)	Randomized controlled trial N = 86 Score = 23	Inclusion: offspring: singleton, healthy, caucasian mother. Exclusion: maternal diabetes, pre-existing hypertensive disorders, mental illness	Maternal pre-pregnancy BMI	DEXA, at 2.5 to 3 years of age	None
Perng et al. ³⁰ (Boston, USA)	Prospective cohort N = 848 Score = 16	Inclusion: singleton pregnancy. Exclusion: maternal diabetes, gestation length less than 34 weeks	Maternal pre-pregnancy BMI Gestational weight gain	DEXA, at 6-10 years of age	Maternal race/ethnicity, parity
Pereira-da-Silva et al. ⁴⁰ (Lisbon, Portugal)	Retrospective cohort N = 100 Score = 15	Inclusion: proper medical surveillance, singleton full-term neonate, adequade gestational age *, healthy offspring Exclusion: adverse conditions potentially affecting fetal nutrition and growth, reported consumption of alcohol, tobacco, or illicit drugs	Maternal pre-pregnancy BMI	ADP, at 72 hours after birth	Percentage of total energy value from carbohydrate or from protein
Shapiro et al. ³³ (Denver, USA)	Prospective cohort N = 951 Score = 16	Exclusion: preexisting diabetes type 1 or 2, a prior premature birth or fetal death, asthma with steroid management, serious psychiatric illness or a current multiple pregnancy	Maternal pre-pregnancy BMI	ADP, at 48 hours after birth
Starling et al. ³⁷ (Denver, USA)	Prospective cohort N = 826 Score = 16	Exclusion: preexisting diabetes type 1 or 2, a prior premature birth or fetal death, asthma with steroid management, serious psychiatric illness or a current multiple pregnancy	Maternal pre-pregnancy-BMI	ADP, at ≤ 3 days of age
Castillo et al. ³¹ (Pelotas, Brazil)	Prospective cohort N = 3,156 Score = 18	Inclusion: singleton pregnancy	Maternal pre-pregnancy BMI Gestational weight gain	ADP, at 6 years	Maternal: family income, schooling at birth, skin color, age, parity, smoking and alcohol consumption during pregnancy, history of arterial hypertension, history of diabetes mellitus, gestational age. Offspring: birthweight and sex.
Andrés et al. ³⁶ (Kansas City, USA)	Prospective cohort N = 325 Score = 17	Inclusion: pregnancy uncomplicated, nonsmokers, who denied alcohol use during pregnancy. Singleton full-term offspring, exclusively breast-fed until at least age 6 months	Maternal pre-pregnancy BMI	DEXA, at 6 years	Maternal: race, gestational age. Offspring: birthweight and mode of infant feeding.

Author	Maternal exposure (pre-gestational BMI)	Offspring outcome/Measures of effect	Crude analyses	Adjusted analyses
Studies that assessed body fat percent
Berkowitz et al. ³⁴	High risk	Body fat % (percentage point) at 4 years, mean (SD)	21.0 (6.2)	-
	Low risk		20.3 (3.4)	-
	High risk	Body fat % (percentage point) at 6 years, mean (SD)/β (SE)	24.7 (11.8)	112.3 (77.4)
	Low risk		18.8 (4.5) *	Reference
Sewell et al. ²⁹	< 25kg/m²	Body fat % (percentage point) at 72 hours, mean (SD)	9.6 (4.3)	-
Sewell et al. ²⁹	≥ 25kg/m²		11.0 (4.7) *	-
Burdette et al. ³⁵	≥ 30kg/m²	Hight adiposity (%) at 6 years, %/OR (95%CI)	30.8	0.95 (0.4; 2.1)
Burdette et al. ³⁵	< 30kg/m²		23.4	Reference
Hull et al. ⁵	< 25kg/m²	Body fat % (percentage point) at 35 days, mean (SD)	12.5 (4.2)	-
Hull et al. ⁵	≥ 25kg/m²		13.6 (4.3) *	-
Hull et al. ⁶	< 25kg/m²	Body fat % (percentage point) at 24-48 hours, mean (SD)	11.7 (4.1)	-
	25-30kg/m²		13.0 (4.7)	-
	> 30kg/m²		14.6 (4.3)	-
Au et al. ²⁷	<18.5kg/m²	Body fat % (percentage point) at 48 hours, mean (SD)/β (95%CI)	8.8 (4.1)	-0.2 (-1.5; 1.2)
	18-24kg/m²		9.0 (4.2)	Reference
	25-29kg/m²		9.9 (4.8)	1.2 (0.3; 2.1) *
	30-34kg/m²		9.0 (4.5)	-0.9 (-2.8; 0.9)
	> 35kg/m²		-	3.1 (0.7; 5.5) *
Carlsen at al. ³²	18-24kg/m²	Body fat % (percentage point) at 48 hours, mean (SD)/β (95%CI)	8.8 (3.6) *	Reference
	≥ 30kg/m²		11.2 (4.3)	3.1 (2.0; 4.1)
Tanvig et al. ³⁹	18-24kg/m²	Body fat % (percentage point) at 2.5-3 years, mean (95%CI)	21.3 (19.5; 23.1)	-
	≥ 30kg/m²		21.6 (19.4; 23.8)	-
Pereira-da-Silva et al. ⁴⁰	kg/m²	Body fat % (percentage point) at 72 hours, β	0.2	-
	≥ 25kg/m²	Bady fat % (percentage point) at 72 hours, β	0.9	-
Shapiro et al. ³³	< 25kg/m²	Body fat % (percentage point) at 48 hours, mean (SD)	8.8 (3.8)	-
	25-29kg/m²		9.4 (3.9)	-
	≥ 30kg/m²		10.1 (4.0)	-
	kg/m²	Body fat % (percentage point) at 48 hours, β (95%CI)	0.2 (0.1; 0.2)	0.1 (0.04; 0.2)
Starling et al. ³⁷	kg/m²	Body fat % (percentage point) at 3 days, β (95%CI)	-	0.1 (0.1; 0.2)
Castillo et al. ³¹	kg/m²	Body fat % (percentage point) at 6 years, β (95%CI)	0.3 (0.3; 0.4)	0.18 (0.03; 0.3)
	< 18.5kg/m²	Body fat % (percentage point) at 6 years, mean (SD)	20.1 (5.6) **
	18.5-24kg/m²		23.0 (7.5)
	25-29kg/m²		24.7 (8.4)
	≥ 30kg/m²		26.8 (9.5)
Studies that assessed fat mass
Berkowitz et al. ³⁴	High risk	Fat mass (kg) at age 4 years, mean (SD)	3.7 (1.6)	-
	Low risk		3.2 (0.8)	-
	High risk	Fat mass (kg) at 6 years, mean (SD)/β (SE)	6.7 (5.7)	0.3 (0.1) *
	Low risk		3.8 (1.2) *	Reference
Sewell et al. ²⁹	< 25kg/m²	Fat mass (g) at 72 hours, mean (SD)	331 (179)	-
Sewell et al. ²⁹	≥ 25kg/m²		406 (221) *	-
Burdette et al. ³⁵	≥ 30kg/m²	Fat mass (kg) at 5 years, mean (SD)/β (95%CI)	5.0 (0.2)	0.5 (0.02; 0.9)
Burdette et al. ³⁵	< 30kg/m²		4.5 (0.1) *	Reference
Gale et al. ²⁸	kg/m²	FMI (SDS) at 9 years, male, β (95%CI)	0.2 (-0.04; 0.4)	0.3 (0.04; 0.5)
Gale et al. ²⁸		FMI (SDS) at 9 years, female β (95%CI)	0.4 (0.3; 0.5)	0.4 (0.3; 0.6)
Lawlor et al. ³⁸	SD	Fat mass (z-score) at 9-11 years, mean *** (95%CI)	0.3 (0.2; 0.3)	0.3 (0.2; 0.3)
Hull et al. ⁵	< 25kg/m²	Fat mass (g) at 35 days, mean (SD)	414.1 (264.2)	-
	≥ 25kg/m²		448.3 (262.2) *	-
	25-30kg/m²		450.9 (216.3)	-
	> 30kg/m²		489.6 (158.7)	-
Carlsen at al. ³²	18-24kg/m²	Fat mass (g) at 48 hours, mean (SD)/β (95%CI)	331 (163) *	Reference
	≥ 30kg/m²		443 (212)	135 (85; 186)
Pereira-da-Silva et al. ⁴⁰	kg/m²	Fat mass (kg), at 72 hours, β	0.1	-
	≥ 25kg/m²	Fat mass (kg), at 72 hours, β (95%CI)	0.5	0.1 (0.03; 0.2) ^,**
Tanvig et al. ³⁹	18-24kg/m²	Fat mass (kg) at 2.5-3 years, mean (95%CI)	2.3 (2.1; 2.5)	-
	≥ 30kg/m²		2.4 (2.2; 2.7)	-
Perng et al. ³⁰	per 5kg/m²	Fat mass (kg) at 6-10 years, β (95%CI)		0.9 (0.7; 1.1)
Shapiro et al. ³³	< 25kg/m²	Fat mass (g) at 48 hours, mean (SD)	280.5 (143.2)	-
	25-29kg/m²		306.7 (151.9)	-
	≥ 30kg/m²		332.6 (159.6)	-
Starling et al. ³⁷	kg/m²	Fat mass (g) at 3 days, β (95%CI)		5.2 (3.5; 6.9)
Castillo et al. ³¹	kg/m²	Fat mass (kg) at 6 years, β (95%CI)	0.02 (0.1; 0.2)	0.1 (0.03; 0.2)
	kg/m²	FMI (kg/m²) at 6 years, β (95%CI)	0.1 (0.1; 0.1)	0.07 (0.02; 0.1)
	< 18.5kg/m²	Fat mass (kg) at 6 years, mean (SD)	4.5 (1.9) **
	18.5-24kg/m²		5.9 (3.2)
	25-29kg/m²		6.9 (4.0)
	≥ 30kg/m²	FMI (kg/m²) at 6 years, mean (SD)	8.0 (5.2)
	< 18.5kg/m²		3.1 (1.2) **
	18.5-24kg/m²		4.0 (2.0)
	25-29kg/m²		4.5 (2.4)
	≥ 30kg/m²		5.3 (3.0)
Studies that assessed lean mass or fat-free mass
Berkowitz et al. ³⁴	High risk	Lean mass (kg) at 4 years, mean (SD)	13.1 (1.5)	-
	Low risk		12.2 (0.9) *	-
	High risk	Lean mass (kg) at 6 years, mean (SD)	16.7 (1.9)	-
	Low risk		15.6 (1.3) *	-
Sewell et al. ²⁹
	< 25kg/m²	Fat-free mass (g) at 72 hours, mean (SD)	2951 (406)	-
	≥ 25kg/m²		3023 (410)	-
Gale et al. ²⁸	kg/m²	LMI (SDS) at 9 years, male, β (95%CI)	0.2 (0.04; 0.4)	0.2 (-0.02; 0.4)
		LMI (SDS), at 9 years, female, β (95%CI)	0.2 (-0.1; 0.3)	0.1 (-0.1; 0.3)
Lawlor et al. ³⁸	SD	Lean mass (z-score) at 9-11 years, mean *** (95% CI)	0.1 (0.1; 0.1)	0.1 (0.1; 0.1)
Hull et al. ⁵	< 25kg/m²	Fat-free mass (g) at 35 days, mean (SD)	3,310.5 (344.6)	-
	≥ 25kg/m²		3,162.2 (313.4) *	-
Hull et al. ⁶	< 25kg/m²	Fat-free mass (g) at 24-48 hours, mean (SD)	2,826.5 (330.4)	-
	25-30kg/m²		2,903.3 (407.4)	-
	> 30kg/m²		2,833.6 (332.1)	-
Carlsen et al. ³²	18-24kg/m²	Fat-free mass (g) at 48 hours, mean (SD)/β (95%CI)	3,322 (371)	Reference
	≥ 30kg/m²		3,332 (487)	28 (-69; 125)
Tanvig et al. ³⁹	18-24kg/m²	Fat-free mass (kg) at 2.5-3 years, mean (95%CI)	10.9 (10.6; 11.2)	-
	≥ 30kg/m²		11.2 (10.8; 11.7)	-
Pereira-da-Silva et al. ⁴⁰	kg/m²	Fat-free mass (kg), at 72 hours, β	0.01	-
	≥ 25kg/m²	Fat-free mass (kg), at 72 hours, β (95%CI)	0.01	0.3 (0.1; 0.4) ^,**
Shapiro et al. ³³	< 25kg/m²	Fat-free mass (g) at 48 hours, mean (SD)	2,830.7 (324.8)	-
	25-29kg/m²		2,877.0 (366.7)	-
	≥ 30kg/m²		2,853.3 (33.8)	-
Starling et al. ³⁷	kg/m²	Fat-free mass (g) at 3 days, β (95%CI)		7.7 (4.5; 10.9)
Castillo et al. ³¹	kg/m²	Fat-free mass (kg) at 6 years, β (95%CI)	0.1 (0.1; 0.14)	0.13 (0.11; 0.2)
	kg/m²	FFMI (kg/m²) at 6 years, β (95%CI)	0.05 (0.04; 0.1)	0.06 (0.05; 0.1)
	< 18.5kg/m²	Fat-free mass (kg) at 6 years, mean (SD)	17.3 (2.3) **
	18.5-24kg/m²		18.5 (2.7)
	25-29kg/m²		19.3 (2.9)
	≥ 30kg/m²		19.6 (3.3)
	< 18.5kg/m²	FFMI (kg/m²) at 6 years, mean (SD)	12.1 (1.0) **
	18.5-24kg/m²		12.6 (1.1)
	25-29kg/m²		12.8 (1.1)
	≥ 30kg/m²		13.2 (1.3)

Author	Maternal exposure	Offspring outcome	Crude analyses	Adjusted analyses
Studies that assessed body fat percent
Hull et al. ⁶	Gestational weight gain (kg)	Body fat % (percentage point) at 24-48 hours, mean (SD)	12.3 (4.4)	-
	Pre-gestational weight BMI 18-24kg/m²/Gestational weight gain	Body fat % (percentage point) at 24-48 hours, mean (SD)	11.7 (4.1)
	Adequade			11.2 (0.5)
	Excessive			11.8 (0.5)
	Pre-gestational weight BMI 25-29kg/m²/Gestational weight gain		13.0 (4.7)	-
	Adequade		-	9.2 (1.1)
	Excessive		-	13.7 (0.7)
	Pre-gestational weight BMI ≥ 30kg/m²/Gestational weight gain		14.6 (4.3)
	Adequade		-	14.6 (1.4)
	Excessive		-	14.2 (0.8)
Josefson et al. ⁴¹	Gestational weight gain
	Adequate	Body fat % (percentage point) at 72 hours, mean (SD)	10.7 (2.8)	-
	Excessive		13.9 (3.3)	-
Henriksson et al. ⁴⁴	Gestational weight gain
	Inadequate	Body fat % (percentage point) at 2-11 days, mean (SD)	11.1 (4.1)	-
	Adequate		11.9 (4.1)	-
	Excessive		13.0 (3.8)	-
Sewell et al. ²⁹	Gestational weight gain (lb)/Pre-gestational BMI ≥ 25kg/m²	Body fat % (percentage point) at 72 hours, r	0.4	-
Au et al. ²⁷	Gestational weight gain (kg)	Difference in body fat %, β (95%CI)		0.1 (0.1; 0.2)
Starling et al. ³⁷	Gestational weight gain (kg)	Body fat % (percentage point) at 3 days, β (95%CI)		0.6 (0.4; 0.7)
Castillo et al. ³¹	Gestational weight gain (kg)	Body fat % (percentage ppoint) at 6 years, β (95%CI)	0.16 (0.12; 0.21)	0.18 (0.13; 0.23)
	Insufficient	Body fat % (percentage point) at 6 years, mean (SD)	22.1 (7.4)
	Sufficient		23.5 (7.8)
	Excessive		25.4 (8.5)
Studies that assessed fat mass
Crozier et al. ⁴²	Gestational weight gain (kg)	Fat mass (kg²), β (95%CI)
		At birth	0.1 (0.0; 0.1)	-
		At 4 years	-0.01 (-0.1; 0.1)	0.0 (-0.1; 0.1)
		At 6 years	0.1 (-0.0; 0.1)	0.1 (-0.0; 0.1)
	Gestational weight gain
	Inadequate	Fat mass (kg²) at birth, β (95%CI)	-0.1 (-0.3; 0.1)	-0.1 (-0.3; 0.1)
	Excessive		0.1 (-0.0; 0.3)	0.2 (0.0; 0.3)
	Inadequate	Fata mass (kg²) at 4 years, β (95%CI)	0.2 (-0.1; 0.4)	0.2 (-0.1; 0.4)
	Excessive		0.2 (0.0; 0.4)	0.1 (-0.0; 0.3)
	Inadequate	Fat mass (kg²) at 6 years, β (95%CI)	0.2 (-0.1; 0.4)	0.2 (-0.1; 0.4)
	Excessive		0.4 (0.2; 0.5)	0.3 (0.1; 0.5)
Gale et al. ²⁸	Gestational weight gain (kg), SDS	FMI (SDS) male, β (95%CI)	0.1 (-0.1; 0.3)	0.1 (-0.1; 0.3)
		FMI (SDS) female, β (95%CI)	0.01 (-0.2; 0.2)	0.1 (-0.0; 0.3)
Henriksson et al. ⁴⁴	Gestational weight gain
	Inadequate	Fat mass (g) at 2-11 days, β (95%CI)	-54 (-111; 4)	-30 (-78; 18)
	Excessive		55 (10; 100)	37 (-1; 75)
Perng et al. ³⁰	Gestational weight gain BMI per 5kg/m²	Fat mass (kg) at 6-10 years, β (95%CI)		0.3 (0.1; 0.5)
Hull et al. ⁶	Gestational weight gain (kg)	Fat mass (g) at 24-48 hours, mean (SD)	408.5 (179.7)	-
	Pre-gestational BMI 18-24kg/m²/Gestational weight gain	Fat mass (g) at 24-48 hours, mean (SD)	382.4 (165.7)
	Adequade		-	355.5 (20.1)
	Excessive		-	388.90 (21.9)
	Pre-gestational BMI 25-29kg/m²/Gestational weight gain		450.9 (216.3)	-
	Adequade		-	303.6 (46.1)
	Excessive		-	484.40 (28.8)
	Pre-gestational BMI ≥ 30kg/m²/Gestational weight gain		489.6 (158.7)
	Adequade			472.9 (56.0)
	Excessive			486.40 (33.5)
Josefson et al. ⁴¹	Gestational weight gain
	Sufficient	Fat mass (g) at 72 hours, mean (SD)	348 (103)	-
	Excessive		525 (178)	-
Henriksson et al. ⁴⁴	Gestational weight gain
	Inadequate	Fat mass (g) at 2-11 days, mean (SD)	384 (178)	-
	Sufficient		438 (186)	-
	Excessive		493 (177)	-
Sewell et al. ²⁹	Gestational weight gain (lb)/Maternal pre-gestational BMI < 25kg/m²	Fat mass (g) at 72 hours, r	0.12 *	-
Estampador et al. ⁴³	Gestational weight gain
	Midpregnancy	Fat mass (z-score) at 4 months, r (95%CI)	0.4 (0.04; 0.7) *	-
	Late-pregnancy		-0.02 (-0.4; 0.7)	-
Starling et al. ³⁷	Gestational weight gain (kg)	Fat mass (g) at 3 days, β ( 95%CI)		24.0 (17.4; 30.5)
Studies that assessed fat mass
Castillo et al. ³¹	Gestational weight gain (kg)	Fat mass (kg) at 6 years, ß (95%CI)	0.08 (0.06; 0.10)	0.08 (0.06; 0.11)
	Gestational weight gain (kg)	FMI (kg/m²) at 6 years, ß (95%CI)	0.04 (0.03; 0.06)	0.05 (0.04; 0.06)
	Gestational weight gain
	Insufficient	Fat mass (kg) at 6 years, mean (SD)	5.5 (3.1)
	Sufficient		6.1 (3.5)
	Excessive		7.2 (4.3)
	Insufficient	FMI (kg/m²) at 6 years, mean (SD)	3.8 (2.0)
	Sufficient		4.1 (2.1)
	Excessive		4.7 (2.5)
Studies that assessed fat-free mass or lean mass
Crozier et al. ⁴²	Gestational weight gain (kg)	Fat-free mass (kg), ß (95%CI)
		at birth	0.01 (-0.03; 0.1)	^-
		at 4 years	0.01 (-0.03; 0.1)	0.04 (-0.01; 0.1)
		at 6 years	-0.01 (-0.1; 0.04)	-0.01 (-0.1; 0.1)
	Gestational weight gain
	Inadequate	Fat-free mass (kg) at birth, ß (95%CI)	-0.03 (-0.2; 0.1)	-0.04 (-0.2; 0.1)
	Excessive		0.02 (-0.1; 0.1)	0.1 (-0.1; 0.2)
	Inadequate	Fat-free mass (kg) at 4 years, ß (95%CI)	0.1 (-0.1; 0.2)	0.2 (-0.1; 0.4)
	Excessive		0.1 (-0.1; 0.2)	0.1 (-0.03; 0.3)
	Inadequate	Fat-free mass (kg) at 6 years, ß (95%CI)	0.1 (-0.1; 0.2)	0.03 (-0.1; 0.2)
	Excessive		0.1 (-0.1; 0.2)	0.03 (-0.1; 0.2)
Gale et al. ²⁸	Gestational weight gain (kg), SDS	LMI (SDS)
		Male ß (95%CI)	-0.1 (-0.2; 0.1)	-0.1 (-0.2; 0.1)
		Female ß (95%CI)	-0.02 (-0.2; 0.2)	0.01 (-0.2; 0.2)
Henriksson et al. ⁴⁴	Gestational weight gain
	Inadequate	Fat-free mass (g) at 2-11 days, ß (95%CI)	-152 (-263; -41)	-13 (-77; 51)
	Excessive		101 (15; 187)	39 (-12; 89)
Hull et al. ⁶	Gestational weight gain (kg)	Fat-free mass (g) at 24-48 hours, mean (SD)	2,842.2 (346.8)	-
	Pre-gestational BMI 18-24kg/m²/Gestational weight gain	Fat-free mass (g) at 24-48 hours, mean (SD)	2,826.5 (330.4)	-
	Adequade		-	2758.7 (32.8)
	Excessive		-	2856.60 (35.7)
	Pre-gestational BMI 25-29kg/m²/Gestational weight gain		2,903.3 (407.4)
	Adequade			2839.7 (75.3)
	Excessive			2968.80 (47.0)
	Pre-gestational BMI 30kg/m²/Gestational weight gain		2,833.6 (332.1)
	Adequade		-	2792.5 (91.5)
	Excessive		-	2913.20 (54.7)
Josefson et al. ⁴¹	Gestational weight gain
	Sufficient	Fat-free mass (g), at 72 hours, mean (SD)	2,898 (327)	-
	Excessive		3,174 (415)	-
Studies that assessed fat-free mass or lean mass
Henriksson et al. ⁴⁴	Gestational weight gain
	Inadequate	Fat-free mass (g), at 2-11 days, mean (SD)	2,986 (343)	-
	Sufficient		3,138 (328)	-
	Excessive		3,239 (364)	-
Sewell et al. ²⁹	Gestational weight gain (lb)/Maternal pre-gestational BMI
	< 25kg/m²	Fat-free mass (g) at 72 hours, r	0.20	0.19
	≥ 25kg/m²		0.08	-
Estampador et al. ⁴³	Gestational weight gain
	Mid-pregnancy	Fat-free mass (z-score) at 4 months, r (95%CI)	0.1 (-0.3; 0.4) *	-
	Late-pregnancy		0.4 (0.01; 0.6)	-
Starting et al. ³⁷	Gestational weight gain (kg)	Fat-free mass (g) at 3 days, ß (95%CI)		34.0 (21.4; 46.6)
Castillo et al. ³¹
	Gestational weight gain (kg)	Fat-free mass (kg) at 6 years, ß (95%CI)	0.06 (0.04; 0.07)	0.04 (0.02; 0.05)
	Gestational weight gain (kg)	FFMI (kg/m²) at 6 years, ß (95%CI)	0.01 (0.006; 0.02)	0.01 (0.01; 0.02)
	Insufficient		18.2 (2.7)
	Sufficient		18.7 (2.8)
	Excessive	Fat-free mass (kg) at 6 years, mean (SD)	19.3 (3.0)
	Insufficient		12.6 (1.1)
	Sufficient		12.7 (1.1)
	Excessive	FFMI (kg/m²) at 6 years, mean (SD)	13.0 (1.2)

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[1] Correspondence H. Castillo-Laura. Departamento de Medicina Preventiva, Faculdade de Medicina, Universidade Federal de Pelotas. Rua Marechal Deodoro 1160, 3^o andar, C.P. 464, Pelotas, RS 96020-220, Brasil. helenclaura@gmail.com