title: Cesarean section and increased body mass index in school children: two cohort studies from distinct socioeconomic background areas in Brazil.
abstract: BACKGROUND
  Recent studies have raised controversy regarding the association between cesarean section and later obesity in the offspring. The purpose of this study was to assess the association of cesarean section with increased body mass index (BMI) and obesity in school children from two Brazilian cities with distinct socioeconomic backgrounds.
  
  
  METHODS
  Two birth cohorts respectively born in 1994 in Ribeirao Preto, a wealthy city in Southeast, and in 1997/98 in Sao Luis, a less wealthy city in Northeast of Brasil, were evaluated. After birth, 2,846 pairs of mothers-newborns were evaluated in Ribeirao Preto and 2,542 in Sao Luis. In 2004/05, 790 children aged 10/11 years were randomly reassessed in Ribeirao Preto and 673 at 7/9 years in Sao Luis. Information on type of delivery, maternal and child characteristics, socioeconomic position and anthropometric measurements were collected after birth and at school age. Obesity was defined as BMI ≥ 95th percentile at school age.
  
  
  RESULTS
  Obesity rate was 13.0% in Ribeirao Preto and 2.1% in Sao Luis. Cesarean section was associated with obesity and remained significant after adjustment only in Ribeirao Preto [OR = 1.74 (95% CI: 1.04; 2.92)]. The association between cesarean section and BMI remained significant after adjustment for maternal schooling, maternal smoking during pregnancy, duration of breastfeeding, gender, birth weight and gestational age, type of school and, only in Sao Luis, pre-pregnancy maternal weight. In Ribeirao Preto children born by cesarean section had BMI 0.31 kg/m2 (95% CI: 0.11; 0.51) higher than those born by vaginal delivery. In Sao Luis BMI of children born by cesarean section was 0.28 kg/m2 higher (95% CI: 0.08; 0.49) than those born by vaginal delivery.
  
  
  CONCLUSIONS
  A positive association between cesarean section and increased BMI z-score was demonstrated in areas with different socioeconomic status in a middle-income country.
authors.forename: Marcelo Zubaran
authors.initials: MZ
authors.lastname: Goldani
authors.forename: Marco Antonio
authors.initials: MA
authors.lastname: Barbieri
authors.forename: Antônio Augusto Moura
authors.initials: AA
authors.lastname: da Silva
authors.forename: Manoel Romeu Pereira
authors.initials: MR
authors.lastname: Gutierrez
authors.forename: Heloisa
authors.initials: H
authors.lastname: Bettiol
authors.forename: Helena Ayako Sueno
authors.initials: HA
authors.lastname: Goldani
mesh_terms: D001724:Birth Weight; D015992:Body Mass Index; D001938:Brazil / Q000453:epidemiology; D001942:Breast Feeding; D002585:Cesarean Section; D002648:Child; D015331:Cohort Studies; D005260:Female; D005865:Gestational Age; D006801:Humans; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D009765:Obesity / Q000453:epidemiology* / Q000209:etiology; D012307:Risk Factors; D012959:Socioeconomic Factors