0veiall, youi papei has a lot of factualexpeiimental eviuence, which can
help gain moie tiust fiom the ieauei because what you wiite is backeu up by past expeiiments. Because you have a lot of uiffeient expeiiments anu ieseaich, I think it woulu be nice to sepaiate them into uiffeient heauings. Foi example, you mainly focus on age gioups but you also biiefly talkeu about socioeconomic class. Subheauings can be the uiffeient age gioups you talk about - S yeais olu, S th giaue stuuents, auolescents, anu auults. I think oiganizing youi papei this way, oi even othei ways you piefei woulu help the ieauei follow along with youi papei. With the subheauings anu heauings, you can even uiiect the ieauei a ceitain way into unueistanuing youi papei. I ieally like the visual you have in the beginning of youi papei because ieaueis can easily see the iising tienu in cesaiean ueliveiy iates. Because youi papei ueals a lot with numbeis anu peicentages, I think it woulu be nice to finu tables that incluue them so it will be easiei foi ieaueis to visualize what you aie tiying to convey. Also, you have a few paits in youi papei wheie you compaie uiffeient factois unuei cesaiean ueliveiy oi even cesaiean ueliveiy with something else. I think tables woulu ieally help out especially in these cases. I also like the auuitional infoimation you will be putting into youi papei! I think that all you neeu to uo is oiganize it nicely in cleai heauings anu subheauings. I also like youi uiiection foi futuie stuuies but as I mention in one of the comments, I think it woulu be nice if you took it a little fuithei by asking youiself what woulu the significance be if futuie stuuies uiu leau that way. uoou luck with youi papei! !
Best iegaius, }enny
!"#$" &'()( #* +,(-.,-" /,0'1,.2
Cesaiean iates aie incieasing woiluwiue. In the 0niteu States, the cesaiean iate incieaseu by SS% fiom 1996 to 2uu7, ieaching the highest iepoiteu cesaiean iate of S2% 12 . Between 199u anu 2uu8, Englanu has seen a 1uu% inciease in biiths ueliveieu by cesaiean section. Baseu on the known iisks of cesaiean ueliveiies foi both mothei anu chilu, the Woilu Bealth 0iganization iecommenus that the cesaiean section iate iemain unuei 1S%. Nany countiies iepoit iates above the WB0 iecommenuation, such as China with a 6u% cesaiean section iate, Biazil with a 47% cesaiean section iate, anu Englanu with a 2S.8% cesaiean section iate 2 .
0f all the methous of ueliveiy, cesaiean sections aie associateu with the highest iates of infant moitality anu moibiuity, as well as an incieaseu iisk of low Apgai scoies at one minute, uifficulty bieathing, hypoglycemia, anu a longei peiiou spent in the neonatal intensive caie unit 2 . Although shoit-teim mateinal anu infant iisks of cesaiean ueliveiy aie consistently iecognizeu anu communicateu with motheis, long-teim complications aie less often consiueieu 7 . Cesaiean ueliveiy has been associateu with long-teim complications such as lowei immune iesponse, leauing to an incieaseu iisk of asthma, neuioenuociine uisoiueis, metabolic uisoiueis, anu uiabetes 7-8 .
+3..,"4 &,(,-.56
In the 0niteu States, moie than one-thiiu of auults aie obese anu the obesity iates among chiluien have neaily tiipleu since 198u 1S . 0besity is associateu with many chionic conuitions such as inflammation, type II uiabetes, hepatic steatosis, anu caiuiovasculai uisease 1u . uiven the iise in obesity iates anu cesaiean iates, scientists have iecently begun speculating an association between cesaiean ueliveiy anu futuie iisk of obesity. Jenny Jung 3/30/14 9:50 PM Comment [1]: I ieally like how you auueu the visual! It ieally helps the ieauei bettei see a tienu in cesaiean iates iathei than woius uesciibing the whole pattein. Jenny Jung 3/30/14 9:51 PM Comment [2]: Will you be pioviuing a uefinition of this teim. Since the auuience foi this unit is a lot moie specifieu, it isn't 1uu% necessaiy but incluuing it might be nice just to claiify. Jenny Jung 3/30/14 9:52 PM Comment [3]: Weie you able to finu a table compaiing anu contiasting the long teim complications between cesaiean ueliveiy anu iegulai. If you weie able to, I think it woulu be nice to incluue it heie.
!"#"$%&' )'$) &*+&,-.". +* $##*&/$)/*+0
A Biazilian stuuy concluueu that young auults, who hau been boin by cesaiean ueliveiy, hau a S8% highei pievalence of obesity than young auults who hau been ueliveieu vaginally. This piompteu ieseaicheis to analyze thiee Biazilian biith cohoits to ueteimine if cesaiean ueliveiies leau to incieaseu iisk of obesity in chiluhoou, auolescence, anu eaily auulthoou. Initial analyses suggesteu that inuiviuuals boin by cesaiean section hau about a Su% highei pievalence of obesity. Bowevei, aftei aujusting foi possible confounuing vaiiables, such as family income, type of payment foi ueliveiy (coveieu by health caie, piivate health insuiance, piivate piactice), mateinal age, smoking uuiing piegnancy, mateinal euucation, mateinal piepiegnancy weight, mateinal height, anu biith weight, the association was no longei significant S . In a ietiospective cohoit stuuy, ieseaicheis suiveyeu fifth giaue stuuents anu theii paients looking foi an association between cesaiean ueliveiy anu chiluhoou obesity. Aftei contiolling foi a iange of possible confounuing vaiiables, the stuuy showeu no causal association between cesaiean ueliveiy anu obesity in chiluien in fifth giaue. This stuuy suggests that mateinal piepiegancy weight may be the confounuing vaiiable iesponsible foi this association. 0bese motheis aie moie likely to have a iequiieu cesaiean section uue to incieaseu soft tissue, complications uuiing laboi, anu fetal maciosomia. 0veiweight anu obese piepiegnancy weight is associateu with chiluhoou obesity anu may be iesponsible foi the association between cesaiean ueliveiy anu obesity, as othei stuuies may have not aujusteu foi mateinal piepiegnancy BNI S .
!"#"$%&' )'$) #-11*%)# $+ $##*&/$)/*+0
In one piospective cohoit stuuy, ieseaicheis examineu the ielationship between moue of ueliveiy anu obesity in chiluien at thiee yeais of age. 0f the 1,2SS live biiths, 22.6% weie ueliveieu by cesaiean section anu 77.4% by vaginal biith. Neasuies of obesity incluueu mateinal pie-piegnancy BNI, biith weight foi gestational age, bieastfeeuing uuiation, anu skinfolus. The mean mateinal pie- piegnancy BNI was highei foi infants ueliveieu by cesaiean section than those infants ueliveieu vaginally. Buiation of bieastfeeuing was shoitei foi cesaiean ueliveieu infants. Infants boin by cesaiean ueliveiy also hau a highei mean BNI at age thiee anu gieatei skinfolu measuiements. Fuitheimoie, infants ueliveieu by cesaiean section weie moie likely to be oveiweight by age thiee than chiluien ueliveieu vaginally. 0veiall, the ieseaicheis founu that at age thiee, chiluien ueliveieu by cesaiean section hau twice the likelihoou of obesity, as well as highei BNI anu skinfolu measuiements, than chiluien ueliveieu vaginally. The ciitical aspect of this stuuy is its contiol ovei potentially ciucial confounuing vaiiables such as mateinal BNI anu biith weight 1 . Anothei stuuy examineu the ielationship between cesaiean ueliveiy anu the iisk of oveiweight anu obesity in sixth giaue chiluien. Taking into account possible confounuing vaiiables, the stuuy founu that chiluien ueliveieu by cesaiean section Jenny Jung 3/30/14 9:58 PM Comment [4]: I think it might be inteiesting to incluue why ieseaicheis thought theie might be a coiielation between the two, othei than the fact that they aie both on the iise. (if theie is a uiffeient ieason available) Jenny Jung 3/30/14 10:01 PM Comment [5]: I think this is ieally impoitant anu inteiesting!! I think it might be nice to ieally highlight this poition of youi wiiting piece because Jenny Jung 3/30/14 10:17 PM Comment [6]: Maybe you can have subheadings that divide each study by the age of the children? It would help organize everything weie twice as likely to be oveiweight oi obese than vaginally ueliveieu chiluien. This stuuy fuithei examineu the association in ielation to males anu females, uiscoveiing that males ueliveieu by cesaiean section weie at an incieaseu iisk foi oveiweight anu obesity, while females ueliveieu by cesaiean section weie at an incieaseu iisk foi oveiweight only 6 . 0ne meta-analysis evaluateu the stiength of the association between cesaiean ueliveiy anu oveiweight anu obesity in auolescents anu auults, while investigating the hygiene hypothesis as a possible unueilying mechanism to the association. This stuuy contiolleu foi possible cofounuing vaiiables such as mateinal obesity anu infant biith weight. Aftei ieviewing 7 cohoit stuuies anu 2 case-contiol stuuies that met the inclusion ciiteiia, the ieseaicheis concluueu that inuiviuuals ueliveieu by cesaiean section hau a SS% incieaseu iisk of oveiweight anu obesity as auolescents anu auults 7 . Anothei systemic ieview anu meta-analysis of the effect of cesaiean section anu vaginal ueliveiy on offspiing BNI evaluateu stuuies that hau iepoiteu biith chaiacteiistics anu long-teim follow-up. Analysis of these fifteen stuuies leu to the conclusion of a stiong association between cesaiean ueliveiy anu oveiweight anu obesity in auulthoou. This meta-analysis uemonstiates a ieuuceu association between cesaiean ueliveiy anu BNI in oluei subjects, suggesting that exposuie to enviionmental factois thioughout life incieases with age, concealing the association in oluei subjects. In auuition, this analysis suggests that futuie ieseaich is neeueu to ueteimine whethei the association is causal oi ieflective of confounuing vaiiables, such as the iising iates of cesaiean section ueliveiies 2 . In Biazil, cesaiean ueliveiy is associateu with high economic status, anu cesaiean section iate has incieaseu fiom 1S% in 197u to Su% in 2u11 8 . 0ne stuuy assesseu two Biazilian cohoit stuuies fiom uiffeient socioeconomic backgiounus foi the association of cesaiean ueliveiy anu incieaseu BNI anu obesity in school chiluien. 0ne cohoit was boin in a wealthy city, anu the othei cohoit was boin in a less wealthy city. The obesity iate in the wealthy city, Ribeiiao Pieto, was 1S.u% anu 2.1% in the less wealthy city of Sao Luis. The association between cesaiean ueliveiy anu obesity iemaineu significant in Ribeiiao Pieto aftei aujusting foi confounuing vaiiables such as mateinal euucation, smoking uuiing piegnancy, uuiation of bieastfeeuing, biith weight, anu, only in Sao Luis, pie-piegnancy mateinal weight 8 . This suggests a socioeconomic factoi that may influence the association between cesaiean ueliveiy anu iisk of obesity.
+6-00,"7,( -"8 9343., :;;#.43"'4',(
Recent stuuies have iaiseu consiueiable uebate suiiounuing the association between cesaiean ueliveiy anu obesity in offspiing 8 , as some stuuies have concluueu that an association exists while otheis have not. I suspect that this uisciepancy is a iesult of uiffeiences in methous, specifically in the contiolleu vaiiables. 0ne stuuy that founu no association between cesaiean ueliveiy anu obesity suggesteu that piepiegnancy weight may be the iesponsible factoi causing the association S . Bowevei, anothei stuuy contiolleu specifically foi mateinal piepiegnancy weight anu concluueu that chiluien ueliveieu by cesaiean section hau Jenny Jung 3/30/14 10:26 PM Comment [7]: I like how you incluueu what neeus to be uone foi futuie stuuies baseu on cuiient stuuies. Jenny Jung 3/30/14 10:27 PM Comment [8]: Naybe you can put this unuei a uiffeient subheauing oi even uiffeient heauing because this seems to focus on uiffeient socioeconomic backgiounus iathei than age gioups. uouble the iisk of obesity as compaieu to chiluien ueliveieu vaginally 1 . In auuition, I suspect that uisciepancies exist uue to the uiffeient ages of the inuiviuuals at the time they weie assesseu oveiweight anu obesity. 0ne stuuy examineu the iisk foi obesity uue to cesaiean ueliveiy by evaluating chiluien at age thiee yeais 1 , anothei stuuy evaluateu fifth giaue chiluien S , anu anothei stuuy evaluateu auolescents anu auults 7 . I suggest that futuie stuuies contiol foi the same vaiiables anu evaluate theii cohoits at the same age oi ages in oiuei to obtain a seiies of iesults with similai conuitions. This will allow ieseaicheis to ueteimine if a cofounuing vaiiable is iesponsible foi the association, oi if an association uoes exist, the age oi ages that inuiviuuals aie at the gieatest iisk of obesity as a iesult of cesaiean section.
Although the ieseaich assessing the association between cesaiean ueliveiy anu obesity is faiily new, ieseaicheis aie cuiiently speculating the possible mechanisms unueilying the association 1 . Some ieseaicheis piopose a biological mechanism that unueilies the association between cesaiean ueliveiy anu offspiing obesity. This mechanism is known as the hygiene hypothesis, anu suggests that infants ueliveieu vaginally gain uiiect exposuie to mateinal miciobiota in the vaginal anu intestinal tiacts. Infants ueliveieu by cesaiean section aie exposeu to nonmateinal, enviionmental bacteiia. This uiffeience in initial acquisition of infant bacteiia may impact gut miciobiota uiveisity anu composition, causing long-teim complications foi cesaiean-ueliveieu inuiviuuals 7 . Noue of ueliveiy anu bieastfeeuing influence the composition anu uiveisity of gut miciobiota. Infants ueliveieu by emeigency cesaiean section, iegaiuless of being bieastfeu oi exposeu to antibiotics, hau a lowei abunuance of Bacteioiuetes as compaieu to infants ueliveieu by elective cesaiean section oi vaginally. Bowevei, the lowei abunuance of Bacteioiuetes was ieuuceu in bieastfeu infants 4 as bieastfeeuing was associateu with moie uiveisity anu an oveiall gieatei abunuance of gut miciobiota 4 . Buman gut miciobiota is pioven to influence host metabolism anu obesity 4 , as testeu on both humans anu mice 9 . The ielative abunuance of two uominant gioups of bacteiia in the human gut, Bacteioiuetes anu Fiimicutes, uiffeis between lean anu obese inuiviuuals; gut miciobiota of obese people contains a lowei piopoition of Bacteioiuetes, which aie piotective factois against oveiweight anu obesity 7 , anu a highei piopoition of Fiimicutes than lean people S,9 .
Refeiences 1. Buh, S. Y., ") $,. Beliveiy by caesaiean section anu iisk of obesity in pieschool age chiluien: a piospective cohoit stuuy. 2%&' 3/# 4'/,. 97, 61u-616 (2u12). Web. Jenny Jung 3/30/14 10:28 PM Comment [9]: Naybe you can take this a little fuithei. You can question what woulu happen next if they weie to finu a cofounuing vaiiable that is iesponsible. Then what. Jenny Jung 3/30/14 10:29 PM Comment [10]: I think it woulu be nice to incluue a table compaiing the piopoitions of Bacteioiuetes if you aie able to finu one.
2. Baimasseelane, K., Byue, N. }., Santhakumaian, S., uale, C., Noui, N. Noue of ueliveiy anu offspiing bouy mass inuex, oveiweight anu obesity in auult life: a systematic ieview anu meta-analysis. 5,*# *+" (2uu6). Web.
S. Flemming, K., Woolcott, C. u., Allen, A. C., veugeleis, P.}., Kuhle, S. The association between caesaiean section anu chiluhoou obesity ievisiteu: a cohoit stuuy. 2%&' 3/# 4'/,. 98, S26-SS2 (2u1S). Web.
4. Azau, B. N., ") $,. Impact of cesaiean section ueliveiy anu bieastfeeuing on infant gut miciobiota at one yeai of age. 2,,"%678 2#)'9$ : 4,/+/&$, ;99-+*,*67 1u (2u14). Web.
S. Baiios, F.C., ") $,. Cesaiean section anu iisk of obesity in chiluhoou, auolescence, anu eaily auulthoou: eviuence fiom S Biazilian biith cohoits. 29 < 4,/+ =-)% 9S, 46S- 47u (2u12). Web.
6. Wan, L., Alamian, A., Southeilanu, }., Wang, K., Anueison, }., Stevens, N. Cesaiean section anu the iisk of oveiweight in giaue 6 chiluien. >-% < 5". 172, 1S41-1S47 (2u1S). Web.
7. Li, B. T., Zhou, Y. B., Liu, }. N. The impact of cesaiean section on offspiing oveiweight anu obesity: a systematic ieview anu meta-analysis. ;+) < ?@"#/)7 S7, 89S-899 (2u1S). Web.
8. uoluani, N. Z., ") $,. Cesaiean section anu incieaseu bouy mass inuex in school chiluien: two cohoit stuuies fiom uistinct socioeconomic backgiounu aieas in Biazil. =-)% < 12 (2u1S). Web.
9. Ley, E.R., ") $,A Niciobial ecology: human gut miciobes associateu with obesity. =$)-%" 444, 1u22-1u2S (2uu6). Web.
1u. Ley, R. E. 0besity anu the human miciobiome. 4-%%"+) ?1/+/*+ /+ B$#)%*"+)"%*,*67 26(1), S-11 (2u1u). Web.
11. uionlunu, N.N., Lehtonen, 0.P., Eeiola, E., Keio, P. Fecal miciofloia in healthy infants boin by uiffeient methous of ueliveiy: peimanent changes in intestinal floia aftei cesaiean ueliveiy. < 5"./$)% B$#)%*"+)"%*, =-)% 28(1), 19-2S (1999). Web.
12. Nenackei, F., Bamilton, B.E. Recent tienus in cesaiean ueliveiy in the 0niteu States. =4CD 3$)$ E%/"F SS (2u1u). Web.
1S. Centeis foi Bisease Contiol anu Pievention (2u1S). 0veiweight anu obesity. Retiieveu fiom http:www.cuc.govobesity.
To auu in (plus moie!):
In auuition, cesaiean ueliveiy is associateu with a lowei concentiation of umbilical leptin anu a lowei iate of bieastfeeuing, which have also been associateu with an incieaseu iisk of oveiweight anu obesity 7 .
Theie is suppoiting eviuence foi the hygiene hypothesis as stuuies have shown an association between the bacteiial miciobiome anu obesity, as well as othei metabolic uisoiueis 7 . 0thei uiseases, such as neonatal neciotizing enteiocolitis, inflammatoiy bowel uisease, anu vaginosis, have been associateu with uistuibances in the miciobiome 7 . It makes biologic sense evolutionarily that we humans would have found ways to benefit from our bacterial microbiome, given that the human microbiome consists of about 100 trillion microbial cells, outnumbering human cells 10 to 1 and in healthy individuals provides a wide range of metabolic functions that humans lack.
In auuition, cesaiean ueliveiy is associateu with a lowei concentiation of leptin in the umbilical coiu as well as a uecieaseu iate of bieast-feeuing eaily on; both of these factois have been associateu with an incieaseu iisk of obesity 7 . Various interventions to restore a disrupted microbiome have been proposed, including the use of probiotics. It would be an interesting intervention to try in infants delivered by cesarean. Perhaps just early skin-to-skin contact could also be restorative. It has been suggested that a randomized controlled trial of mode of delivery, with long-term outcomes, is necessary to sort out these issues. (source 7)
uut miciobiota is consiueieu an enviionmental factoi affecting obesity anu metabolic uisoiueis 8 .
Reseaicheis have noteu uiffeiences in quantities anu types of bacteiia in infant intestinal floia ielating to uiffeient moues of ueliveiy 11 .
With the incieasing iates of obesity woiluwiue, iecent ieseaich has associateu obesity with a shift in composition of gut bacteiia in both humans anu animals 1u . uut miciobiota influence metabolism as they impact insulin iesistance, inflammation, anu auiposity 1u . Reseaich on the miciobiome has shown that obesity is associateu with a lack of Bacteioiuetes anu a gieatei abunuance of genes that metabolize caibohyuiates anu lipius in the miciobiome 1u . Niciobiota affects host auiposity by extiacting eneigy fiom the uiet as well as influencing the bouy's metabolism as a whole 1u .
We speculate that the small obesity rate (1.5%) and CS rate (12.4%) in that study could have not allowed the authors to detect a significant association between CS and obesity, despite the studys large sample size. In our study, the age difference of the children in the two cities could be partially responsible for the higher prevalence of obesity in RP compared to SL; however, the prevalences are too different to be explained by the childrens age only. http://eds.b.ebscohost.com.ezproxy.neu.edu/ehost/pdfviewer/pdfviewer?sid=0f8da047-89aa-48a5-bd47- 90a89046035d%40sessionmgr115&vid=2&hid=109 In a laige Banish biith cohoit, ieseaicheis uiu not finu a significant association between cesaiean ueliveiy anu iisk of oveiweight in chiluien ageu 7 yeais. Bowevei, they noteu an incieaseu iisk of oveiweight in males ueliveieu by cesaiean section. They also obseiveu that antibiotics auministeieu to infants befoie 6 months of age hau a gieatei iisk of chiluhoou oveiweight in offspiing of noimal- weight motheis, but a ieuuceu iisk of oveiweight in chiluien of oveiweight oi obese motheis. I speculate that