Obesity in very early life may not obviously affect a child’s development except for severe cases, which may actually restrict activity or cause respiratory difficulty. However, for children less than 5 years of age, which are overweight (weight-for-height greater than 2 standard deviations) or obese (weight-for-height greater than 3 standard deviations—above the WHO Child Growth Standards median), their condition heralds and correlates directly with the development of noncommunicable diseases (NCDs). These include cardiovascular diseases (heart disease and stroke), diabetes, musculoskeletal disorders, particularly osteoarthritis, and some cancers (including endometrial, breast, ovarian, prostate, liver, gallbladder, kidney, and colon). The enormous healthcare costs of NCDs, many of which have its origins in infancy are being passed on to future generations, threatening not only health but also the development and economic growth of nations.

The epidemic transcends geographical, ethnic, and socioeconomic boundaries, affecting all population groups, with varying disparity. While in some countries like the United States, the prevalence of obesity among young children appears to have leveled off or slightly decreased in 2–5 year olds (Ogden et al., 2014), globally there are more people who are obese than underweight and many low- and middle-income countries are now facing a “double burden” of disease. In Africa, the number of children who are overweight or obese has nearly doubled from 5.4 million in 1990 to 10.6 million in 2014; and nearly half of the children under 5 who were overweight or obese in 2014 lived in Asia (WHO, 2016b). It is not uncommon to find under nutrition and obesity coexisting within the same country, the same community, and the same household.

Although higher weight may be associated with wealth and prosperity in some less developed regions, in more developed regions, weight and BMI tend to be associated with lower SES and minorities. In the United States, for example, among 2–5 years old, 18% of Hispanic boys and 15% of Hispanic girls are obese, compared with a population average of 8.4%. Among children aged 6–11 years, the corresponding percentages were 28.6%, 23.4%, and 17.7% (Ogden et al., 2014). Black and Hispanic children seem to have a higher prevalence of behaviors in early life that pose a risk for obesity, as will be discussed later (Taveras et al., 2010b).

It is increasingly clear that the problem of childhood obesity risk is preceded to a great degree by infant metabolic and growth phenomena. A United States study of children born in 2001 showed that one-third of 9 month old infants were either overweight (> 85th BMI percentile for age) or obesity (> 95th percentile), and at 2 years of age, 34.3% were within these excess weight categories (Moss and Yeaton, 2011). Infant adiposity or increased BMI, as early as 2 weeks of age (Winter et al., 2010) through 24 months of age (Öhlund et al., 2009; Stettler and Iotova, 2010; Moss and Yeaton, 2012), has been associated with a significant increased risk of overweight in toddler or preschool age years. And children who were obese at 9 months or 24 months were 3 times more likely to retain an obese weight at age of 4 years, compared to nonobese children measured during their first 2 years of life (Moss and Yeaton, 2012), and in turn these early changes strongly correlate with adult overweight (De Kroon et al., 2010).

However, on the bright side, gestation and the first 2 years of life shape metabolic, immunologic, sensory, behavioral, developmental, and growth parameters for the rest of a person’s life. This giving us a window of opportunity, which, if well utilized, can provide the greatest return on the investment of our efforts in combating the epidemic.

In 2016, the World Health Assembly welcomed the report of the Commission on Ending Childhood Obesity and its six specific recommendations (WHO, 2016b) (Table 11.1).

We address here the specific maternal health and pregnancy factors that can modulate the risk of childhood obesity, and with greater emphasis, elaborate on the impact of diet, and behavior patterns in infancy which can be addressed to influence an infant’s healthy growth, which is a major determinants of his or her future long-term health. We’ll refer to modifiable factors defined as feeding and related dietary, environmental, or behavioral practices that can be addressed by parents, and direct caregivers, in the immediate child’s environment, in their first years of life.

Prenatal exposure to maternal over nutrition, including maternal preconception overweight status and excess gestational weight gain (GWG) have been consistently identified to associate with higher infant birth weight, or childhood overweight (Woo Baidal et al., 2015). In addition, women with excessive preconception weight (overweight or obese at the start of pregnancy) are also at increased risk of developing gestational diabetes mellitus (GDM) and of requiring higher rates of caesarean section delivery, each of which has been independently associated with later childhood risk for overweight. And overweight women with GDM are 2.8 times as likely, and obese women with GDM were 5.5 times as likely to have an LGA infant as normal-weight women without GDM (Black et al., 2013). Being an LGA infant is in turn an independent risk factor for later childhood obesity.

However, even in the absence of GDM, studies have consistently reported a positive association with maternal BMI and infant birth weight or future childhood obesity risk. Some of these effects may be mediated by excess GWG, which has been shown to be associated with increased fat mass and percentage of neonatal body fat (Starling et al., 2014), as well as increase the risk of childhood obesity measured up to 5–18 years of age (Mamun et al., 2013). In a large Chinese study, the risk of overweight at 3–6 years was doubled in children whose mothers were overweight or obese before pregnancy and experienced excess GWG, compared to children of women with adequate preconception weight and recommended (Guo et al., 2015). Excess GWG also has subsequent effects on the mother. GWG, above the recommended levels, was associated with a threefold higher risk of the mother becoming overweight after pregnancy, even among women who were under or average weight before pregnancy (Gunderson, 2009), perpetuating the likelihood of women entering a subsequent pregnancy at a higher than recommended weight. Timing of dietary influence may also be important. Higher maternal dietary glycemic index and total dietary glycemic load in early pregnancy (11 weeks), but not in late (34 weeks) has been associated with greater adiposity in offspring at 4 and 6 years of age (Okubo et al., 2014). Finally, emerging evidence suggests that independent of maternal prepregnancy BMI, and total energy intake, poor maternal diet quality, as assessed by 24 h dietary recall and a healthy eating index score, can also increase neonatal adiposity, (Shapiro et al., 2016). Further work is needed to identify specific macronutrient ranges associated with most desirable in utero growth.

Lastly, maternal diet may influence childhood dietary patterns in other ways. Recent evidence shows that sensory experiences related to food can begin in utero, and could play a role in establishing food preferences. A variety of flavors can be transmitted from the mother’s diet to amniotic fluid and this experience can modify their future acceptance of similarly flavored foods. For example, infants of mothers who consumed carrot flavored water during the latter part of pregnancy showed preference for carrot flavor when complementary foods were introduced (Mennella et al., 1995,  2001).

This section addresses those approaches, which can influence a child’s healthy growth (with focus on the prevention of an accelerated rate of weight gain during infancy, increased weight for length, BMI, or measures of adiposity during the first 24 months of life and through the toddler age), nutritional status, and development of healthy eating behaviors.

These potentially modifiable factors have been reviewed in depth in previous publications (Dattilo et al., 2012; Weng et al., 2012; Woo Baidal et al., 2015). They are also fully consistent with the WHO Report of the Commission on Ending Childhood Obesity (WHO, 2016b), and specifically, their call to “Provide guidance on, and support for, healthy diet, sleep, and physical activity in early childhood to ensure children grow appropriately and develop healthy habits.”