maternal insulin resistance, triglycerides and cord blood insulin in relation to post-natal weight...

Research: Pathophysiology

Maternal insulin resistance, triglycerides and cord blood

insulin in relation to post-natal weight trajectories and

body composition in the offspring up to 2 years

S. Brunner1, D. Schmid1, K. Huttinger1, D. Much1, E. Heimberg2, E.-M. Sedlmeier3,4,M. Bruderl5, J. Kratzsch6, B. L. Bader3,4, U. Amann-Gassner1 and H. Hauner1,3

1Else Kroner-Fresenius-Center for Nutritional Medicine, Klinikum rechts der Isar, Technische Universitat Munchen, Munich, 2Department of Pediatrics,

Universitatsklinikum Tubingen, 3ZIEL—Research Center for Nutrition and Food Sciences, Nutritional Medicine Unit, 4ZIEL—PhD Graduate School, ‘Epigenetics,

Imprinting and Nutrition’, Technische Universitat Munchen, Freising, 5Institute for Medical Statistics and Epidemiology, Klinikum rechts der Isar, Technische

Universitat Munchen, Munich and 6Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Hospital Leipzig, Leipzig, Germany

Accepted 30 July 2013

Abstract

Aims The intrauterine metabolic environment might have a programming effect on offspring body composition. We

aimed to explore associations of maternal variables of glucose and lipid metabolism during pregnancy, as well as cord

blood insulin, with infant growth and body composition up to 2 years post-partum.

Methods Data of pregnant women and their infants came from a randomized controlled trial designed to investigate

the impact of nutritional fatty acids on adipose tissue development in the offspring. Of the 208 pregnant women

enrolled, 118 infants were examined at 2 years. In the present analysis, maternal fasting plasma insulin, homeostasis

model assessment of insulin resistance and serum triglycerides measured during pregnancy, as well as insulin in umbilical

cord plasma, were related to infant growth and body composition assessed by skinfold thickness measurements and

abdominal ultrasonography up to 2 years of age.

Results Maternal homeostasis model assessment of insulin resistance at the 32nd week of gestation was significantly

inversely associated with infant lean body mass at birth, whereas the change in serum triglycerides during pregnancy was

positively associated with ponderal index at 4 months, but not at later time points. Cord plasma insulin correlated

positively with birthweight and neonatal fat mass and was inversely associated with body weight gain up to 2 years after

multiple adjustments. Subsequent stratification by gender revealed that this relationship with weight gain was stronger,

and significant only in girls.

Conclusions Cord blood insulin is inversely associated with subsequent infant weight gain up to 2 years and this seems

to be more pronounced in girls.

Diabet. Med. 30, 1500–1507 (2013)

Introduction

Because of the increasing global prevalence of childhood

overweight and obesity [1], the identification of early

determinants for adiposity development has received consid-

erable attention. Several studies suggest a role of the

metabolic milieu during pregnancy for fetal and later infant

growth or body composition. The most convincing evidence

comes from studies in the field of gestational diabetes

showing higher rates of macrosomia and increased neonatal

fat mass in diabetic pregnancies [2], as well as a continuous

association between maternal glycaemia and neonatal adi-

posity, even in the non-diabetic range [3]. Maternal insulin

resistance during pregnancy might further translate into

higher weight gain and adiposity in infancy [4]. Besides,

maternal variables of lipid metabolism, including triglyce-

rides, have been shown to be related to fetal growth and

newborn fat mass [5–7], although this association may vary

depending on maternal glucose tolerance status [8] or BMI

category [9]. However, longer-term associations of maternal

lipids with infant growth variables or adiposity beyond birth

are largely unstudied.Correspondence to: Hans Hauner. E-mail [email protected]

(Clinical Trials Registry No; NCT 00362089)

1500ª 2013 The Authors.

Diabetic Medicine ª 2013 Diabetes UK

DIABETICMedicine

DOI: 10.1111/dme.12298

Likewise, insulin in umbilical cord blood, produced by the

fetus in response to maternal glycaemia, has been widely

investigated in relation to neonatal anthropometry and

measures of adiposity [10–12], but data on its relationship

with weight gain and body composition later in infancy are

scarce [11,13,14]. Recent data indicate that girls are already

intrinsically more insulin-resistant than boys at birth [15].

Later on, fetal insulin exposure might have differential

implications for post-natal weight development between the

sexes, with girls being potentially programmed towards

slower growth rates by fetal hyperinsulinemia [14].

We aimed to investigate the relationship of maternal

metabolic variables [insulin, insulin resistance expressed by

homeostasis model assessment (HOMA-IR) and triglyce-

rides] measured in late pregnancy (32nd week of gestation)

and cord blood insulin with infant growth and body

composition from birth up to 2 years of age and to explore

potential sex-specific differences.

Subjects and methods

Data came from the Impact of Nutritional Fatty Acids on

Infant Adipose Tissue Development (INFAT) study, an

open-label randomized controlled trial originally designed

to examine the effect of reducing the maternal dietary n-6:

n-3 fatty acid ratio during pregnancy and lactation on infant

adipose tissue development. The study design and the clinical

results on infant fat mass up to 1 year of age were previously

described [16,17].

In brief, 208 healthy pregnant women with singleton

pregnancies and a pre-pregnancy BMI between 18 and

30 kg/m2 were enrolled and randomly assigned to either an

intervention (n = 104) or a control group (n = 104) from

the 15th week of gestation until 4 months post-partum.

Women in the intervention group received (1) a dietary

supplement containing 1200 mg n-3 long-chain polyunsat-

urated fatty acids per day and (2) nutritional counselling to

normalize the consumption of arachidonic acid to a

moderate level of intake. In contrast, women in the con-

trol group were advised to keep to a healthy diet according

to current recommendations of the German Nutrition

Society. The study protocol was approved by the ethical

committee of the Technische Universit€at M€unchen

(no. 1479/06/2006/2/21) and all participants gave written

informed consent.

Collection of samples

Maternal blood was collected at the 15th and 32nd week of

gestation in the morning after an overnight fast. Immediately

after delivery, umbilical vein ethylenediaminetetraacetic acid

(EDTA) blood samples were collected. Umbilical cord blood

was analysed from 137 newborns. Plasma was prepared by

centrifugation at 2000 g at 4 °C for 10 min and subsequently

aliquoted and stored at �80 °C.

Maternal characteristics and infant anthropometry

Maternal pre-pregnancy weight and height were retrieved

from the maternity card, a booklet containing medical

information related to antenatal and natal care provided to

expecting mothers by their gynaecologist. Maternal glucose

tolerance status was defined based on clinical diagnosis by

the women’s gynaecologist. Clinically diagnosed gestational

diabetes was mostly confirmed by a standardized oral glucose

tolerance test and defined based on thresholds according to

Coustan et al. [18]. In only one case, the diagnosis was based

on elevated glucose at random. The therapy regimen (diet or

insulin treatment) of women with gestational diabetes was

retrieved from their medical record.

The infants were examined at birth (for skinfolds:

3–5 days post-partum), at 6 weeks, 4 months, 1 and 2 years

post-partum. Birthweight, length, sex and gestational age of

the newborn were retrieved from the medical record.

Anthropometric measurements of the infants were taken by

trained investigators according to standardized procedures

[16]. Skinfolds were measured in triplicate with a Holtain

caliper (Holtain Ltd, Crymych, UK) at the left body axis at

four sites (triceps, biceps, subscapular and suprailiac). Body

fat percentage was calculated via predictive skinfold equa-

tions according to Weststrate et al. [19]. Fat mass was

calculated as percentage of body fat multiplied by the current

body weight of the infant. Lean body mass was calculated as

body weight minus fat mass.

Abdominal ultrasonography to estimate subcutaneous

abdominal and preperitoneal fat was performed by two

well-trained paediatricians at 6 weeks, 4 months, 1 and

2 years post-partum according to Holzhauer et al. [20].

What’s new?

• Associations of maternal metabolic variables and cord

blood insulin with infant anthropometry beyond birth

have not been adequately addressed.

• We investigated the relationship of maternal insulin,

homeostasis model assessment of insulin resistance,

triglycerides and cord blood insulin with infant weight

gain and body composition up to 2 years.

• Maternal metabolic variables were transiently related

to infant growth and body composition outcomes.

• Cord blood insulin was inversely associated with

weight gain up to 2 years, and this relationship was

stronger and significant only in girls.

• Fetal insulin exposure might differentially affect sub-

sequent weight gain up to 2 years in both sexes.

ª 2013 The Authors.Diabetic Medicine ª 2013 Diabetes UK 1501

Research article DIABETICMedicine

Laboratory analyses

Plasma insulin was measured by a chemiluminescence

immunoassay using the LIAISON analyser (Diasorin, Salug-

gia, Italy). Inter- and intra-assay coefficients of variation

were both < 4%. Fasting plasma glucose and serum

triglyceride levels were determined by an approved external

laboratory (Synlab Labordienstleistungen, Munich, Germany).

HOMA-IR was calculated from fasting glucose and insulin

according to Matthews et al. [21].

Statistical analysis

Statistical analyses were performed with the R software

package (version 2.8.1; R Foundation for Statistical Comput-

ing, http://www.r-project.org) and Predictive Analytics Soft-

Ware (PASW) software (version 18.0; SPSS Inc., Chicago, IL,

USA). To determine differences in the maternal variables

between the randomized groups, multiple linear regression

models [F-test, analysis of covariance (ANCOVA)] adjusting

for age and pre-pregnancy BMI as additional independent

variables were employed. To analyse differences in cord blood

insulin between the groups or sexes, respectively, Mann–

Whitney tests were used.

To assess associations of the various maternal metabolic

variables at the 32nd week of gestation, and cord blood

insulin with infant clinical outcomes up to 2 years of age,

data of both groups were pooled. Multiple linear regression

models, including the covariates maternal pre-pregnancy

BMI, gestational weight gain, maternal glucose tolerance

status, pregnancy duration, sex and group allocation for the

data at birth, and, additionally, ponderal index at birth and

mode of infant feeding at the later time points, were

performed. A two-sided P-value < 0.05 was considered

statistically significant.

Results

We examined 188 newborns at birth, 180 infants at

6 weeks, 174 at 4 months, 170 at 1 year and 118 at

2 years of age. Maternal, newborn and infant characteris-

tics up to 2 years are presented in Table 1. Individuals who

completed all assessments did not significantly differ from

the rest of the study population in the major socio-demo-

graphic and clinical variables (data not shown). Maternal

fasting insulin and HOMA-IR at the 32nd week of

gestation did not significantly differ between the random-

ized groups (data not shown). In contrast, triglyceride levels

increased significantly less from baseline (15th week of

gestation) until 32nd week of pregnancy in the intervention

compared with the control group (D intervention 76.2 �53.5 mg/dl vs. control 103.6 � 58.1 mg/dl, P < 0.001),

resulting in significantly higher levels in the control group

compared with the intervention group at the 32nd week of

gestation (P < 0.001). Cord plasma insulin concentrations

did not differ by group (data not shown). Girls displayed

significantly higher cord plasma insulin levels compared

with boys (P = 0.037, Table 1), and also when extreme

outliers with very high insulin levels (> 3 9 interquartile

range, n = 7, P = 0.022) were excluded.

Maternal insulin, HOMA-IR and triglycerides at the 32nd

week of gestation in relation to infant clinical outcomes up to

2 years post-partum

Maternal insulin, HOMA-IR and triglyceride levels at the

32nd week of gestation were found to be largely unrelated

to infant growth and body composition outcomes up to

2 years post-partum. However, HOMA-IR was signifi-

cantly inversely associated with lean body mass at birth

[adjusted regression coefficient (badj) (95% CI) �54.94

(�99.23 to �10.64) g, P = 0.016] in the analysis control-

ling for maternal pre-pregnancy BMI, gestational weight

Table 1 Maternal, newborn and 2-year infant characteristics

Maternal variables (n = 208 at baseline)Age at enrollment (years) 31.8 � 4.7Pre-pregnancy BMI (kg/m2) 22.3 � 3.0Parity (primiparae) 58.5Gestational diabetes 9.0Dietary treatment 76.5Insulin treatment 23.5

Gestational weight gain (kg) 15.6 � 4.9Education (≥ 12 years at school) 69.1Energy intake at 32nd week ofgestation (kcal/day) (n = 166)

2079 � 415

Insulin at 32nd week ofgestation (pmol/l) (n = 182)

76.7 � 43.1

HOMA-IR at 32nd week ofgestation (n = 175)

2.2 � 1.2

Triglycerides at 32nd week ofgestation (mg/dl) (n = 187)

197.0 � 66.2

Newborn variables (n = 188)Sex (girls) 47.9Gestational age (weeks) 39.6 � 1.5Birthweight (g) 3443 � 520Ponderal index (kg/m3) 24.8 � 2.4Sum of four skinfolds (mm) (n = 168) 16.0 � 2.6Body fat (%) (n = 168) 13.8 � 2.7Cord blood insulin (pmol/l) (n = 137) 28.30 (36.40)Girls (n = 63) 31.90 (37.10)*Boys (n = 74) 25.85 (24.53)*

Mode of infant feeding (4 months post-partum)Exclusively breastfed 64.6Partially breastfed 15.2Formula fed 20.2

Infant variables at 2 years (n = 118)Body weight (g) 12393 � 1395Ponderal index (kg/m3) 18.8 � 1.8Sum of four skinfolds (mm) (n = 110) 23.7 � 3.4Body fat (%) (n = 110) 19.1 � 2.3Weight gain (birth to 2 years) (g) 8919 � 1306

Data are presented as mean � SD, median (interquartile range)(for cord blood insulin) or percentage.*Significant difference between the sexes (P = 0.037), Mann–Whitney test.



DIABETICMedicine Cord blood insulin in relation to offspring weight gain � S. Brunner et al.

gain, maternal glucose tolerance status, pregnancy dura-

tion, group and sex (see also Supporting Information,

Table S1). Moreover, the change in maternal serum

triglyceride concentration between the 15th and 32nd week

of gestation was weakly, but significantly associated with

infant ponderal index at 4 months post-partum [badj: 0.01

(0 to 0.01) kg/m3, P = 0.020], but not with any of the

other growth or body composition outcomes up to 2 years

post-partum. No significant relationships were found for

absolute triglyceride levels (see also Supporting Informa-

tion, Table S2).

Cord plasma insulin in relation to infant clinical outcomes up

to 2 years post-partum

In the analysis comprising all available data at birth, cord

blood insulin was significantly positively related to birth-

weight [b: 1.68 (0.03 to 3.33) g, P = 0.048], the sum of

four skinfolds [b: 0.02 (0.01 to 0.02) mm, P = 0.001],

percentage body fat [b: 0.02 (0.01 to 0.03)%, P = 0.001],

as well as the absolute amount of fat mass [b: 0.81 (0.31

to 1.31) g, P = 0.002] in the newborns. These relationships

remained significant after adjustment for maternal

pre-pregnancy BMI, gestational weight gain, maternal

glucose tolerance status, pregnancy duration, group and

sex (Table 2). In contrast, significant inverse relationships

of cord blood insulin were found with infant weight, BMI,

fat and lean body mass at 2 years, as well as with weight

gain from birth up to 2 years in the unadjusted analysis

(Table 2). However, in the adjusted model controlling for

maternal pre-pregnancy BMI, gestational weight gain,

maternal glucose tolerance status, pregnancy duration,

group, sex, ponderal index at birth and mode of infant

feeding at 4 months post-partum, only the relationship

with weight gain remained significant [badj: �6.90 (�13.13

to �0.67) g, P = 0.030] (Table 2). When the analysis was

restricted to participants completing all study visits up to

2 years (n = 118, “completers”), significant inverse associ-

ations with infant anthropometrics were already apparent

at 1 year of age (BMI: P = 0.015; sum of four skinfolds:

P = 0.036; percentage body fat: P = 0.027; fat mass:

P = 0.024; weight gain up to 1 year: P = 0.010 in the

adjusted model) (Table 2).

Testing for sex interaction revealed no significant interac-

tion term for the association with weight gain up to 2 years

(P = 0.710). Nevertheless, the relationship of cord blood

insulin with weight gain up to 2 years turned out to be much

stronger in girls compared with boys [girls: badj �7.63

(�15.29 to 0.03) g, P = 0.051; boys: badj �2.82 (�15.76 to

10.11) g, P = 0.662; Fig. 1].

No significant associations were found with the data set on

infant fat mass assessed by ultrasonography, neither for

maternal variables nor for cord blood insulin (data not

shown).

Discussion

In this study, we investigated associations of various

maternal markers of glucose and lipid metabolism and cord

blood insulin with subsequent infant growth and body

composition over the first 2 years of life. The major finding

of our study was that cord blood insulin was inversely

associated with anthropometric measures from the first year

of life onwards, but only the association with weight gain

persisted up to 2 years after adjustment for covariates. This

association was significant only in girls, which is consistent

with recent findings showing cord C-peptide as a proxy for

fetal insulin to be inversely associated with infant weight

development over the 1st year of life in girls, but not in boys

[14].

In accordance with other studies [14,15], we observed

significantly higher cord plasma insulin concentrations in

girls compared with boys, although this was not entirely

consistent across the literature [10–12]. In view of the lower

birthweights but higher cord blood insulin levels in girls, it

was suggested that girls might be inherently more insu-

lin-resistant in utero and around birth compared with boys

[15]. This ‘gender insulin hypothesis’ proposes that

gender-specific genes affecting insulin sensitivity might

account for the gender difference in birthweight [22]. Our

data and previous findings thus might suggest a program-

ming effect of fetal insulin exposure for early weight gain, for

which girls may be more susceptible than boys [14].

The consequences of such an effect with regard to later risk

for metabolic diseases remain to be clarified. It has been

reported that girls are also more insulin-resistant compared

with boys in childhood and that Type 2 diabetes is more

common in girls [23]. Furthermore, observational studies have

related slower early growth patterns with insulin resistance or

diabetes in later life [24,25]. Slower weight gain has also been

reported in infants born to mothers with gestational diabetes

[26], which could be interpreted as a programming effect of

higher fetal insulin concentrations as well.

In contrast to fetal insulin, maternal variables of glucose

metabolism were largely unrelated to the infant clinical

outcomes, except that higher maternal HOMA-IR at the

32nd week of gestation was associated with lower lean body

mass at birth. Although our data showed no explicit

relationship with fat mass, this finding might to some extent

be compatible with data showing increased body fat in

newborns from mothers with gestational diabetes compared

with women with normal glucose tolerance [2] and the direct

association of maternal glucose homeostasis with neonatal

adiposity across the full range of maternal glycaemia, and

not restricted to manifest diabetes [3]. However, in the

follow-up of the Hyperglycaemia and Adverse Pregnancy

Outcome (HAPO) study, no such relationship could be found

with adiposity at 2 years of age within a group of pregnant

women without diabetes [13].



Table

2Umbilicalcord

plasm

ainsulin(pmol/l)in

relationto

infantoutcomes

atbirth,1yearandat2years

post-partum

n

Analysis1‘allavailable

data’‡

Analysis2‘completers

only’§

Unadjusted

model

Adjusted

model¶

Adjusted

model¶

b(95%

CI)†

Pb(95%

CI)†

Pn

b(95%

CI)†

P

Birth Birthweight(g)

137

1.68(0.03to

3.33)

0.048*

1.87(0.27to

3.47)

0.023*

93

0.98(�

0.92to

2.87)

0.308

Ponderalindex

(kg/m

3)

137

�0.00(�

0.01to

0.01)

0.875

�0.00(�

0.01to

0.01)

0.803

93

�0.01(�

0.02to

0.01)

0.382

BMI(kg/m

2)

137

0.00(0

to0.01)

0.434

0.00(�

0.00to

0.01)

0.423

93

�0.00(�

0.01to

0.01)

0.833

Sum

offourskinfold

thicknesses(m

m)

130

0.02(0.01to

0.02)

0.001*

0.02(0.01to

0.03)

0.003*

89

0.01(0.00to

0.03)

0.031*

Bodyfat(%

)130

0.02(0.01to

0.03)

0.001*

0.02(0.01to

0.03)

0.002*

89

0.01(0.00to

0.03)

0.025*

Fatmass

(g)

130

0.81(0.31to

1.31)

0.002*

0.80(0.28to

1.32)

0.003*

89

0.63(0.01to

1.26)

0.045*

Leanbodymass

(g)

130

0.89(�

0.39to

2.17)

0.176

1.01(�

0.21to

2.24)

0.105

89

0.41(�

1.02to

1.85)

0.567

1yearpost-partum

Weight(g)

127

�3.00(�

7.06to

1.06)

0.150

�1.58(�

5.48to

2.32)

0.424

93

�4.37(�

9.04to

0.29)

0.066

BMI(kg/m

2)

127

�0.01(�

0.01to

0)

0.053

�0.00(�

0.01to

0.00)

0.121

93

�0.01(�

0.01to

�0.00)

0.015*

Sum

offourskinfold

thicknesses(m

m)

127

�0.00(�

0.02to

0.02)

0.930

�0.00(�

0.02to

0.02)

0.901

90

�0.02(�

0.04to

�0.00)

0.036*

Bodyfat(%

)123

�0.00(�

0.01to

0.01)

0.733

�0.00(�

0.01to

0.01)

0.765

90

�0.01(�

0.03to

�0.00)

0.027*

Fatmass

(g)

123

�0.73(�

2.44to

0.99)

0.408

�0.43(�

2.18to

1.33)

0.630

90

�2.30(�

4.30to

�0.31)

0.024*

Leanbodymass

(g)

123

�2.39(�

5.15to

0.37)

0.092

�1.17(�

3.78to

1.44)

0.375

90

�2.36(�

5.45to

0.73)

0.133

Weightgain

(g)(birth–1

yearpost-partum)

127

�4.65(�

8.39to

�0.92)

0.016*

�3.36(�

7.02to

0.28)

0.071

93

�5.77(�

10.15to

�1.39)

0.010*

2years

post-partum

Weight(g)

93

�7.60(�

13.79to

�1.41)

0.017*

�5.50(�

12.12to

1.13)

0.103

BMI(kg/m

2)

93

�0.01(�

0.01to

�0.00)

0.021*

�0.01(�

0.01to

0.00)

0.115

Sum

offourskinfold

thicknesses(m

m)

90

�0.01(�

0.01to

0.00)

0.064

�0.01(�

0.03to

0.01)

0.226

Bodyfat(%

)90

�0.01(�

0.02to

0.01)

0.269

�0.01(�

0.02to

0.01)

0.249

Fatmass

(g)

90

�2.36(�

4.65to

�0.07)

0.043*

�2.02(�

4.48to

0.43)

0.105

Leanbodymass

(g)

90

�5.60(�

10.00to

�1.21)

0.013*

�3.80(�

8.45to

0.85)

0.108

Weightgain

(g)(birth–2

years

post-partum)

93

�8.66(�

14.46to

�2.85)

0.004*

�6.90(�

13.13to

�0.67)

0.030*

*P<0.05.

†Data

are

presentedastheregressioncoefficient(b)alongwiththe95%

confidence

interval.

‡Analysis1wasbasedonallavailable

data

attherespectivetimepoints.

§Analysis2wasbasedonthecohort

withfulldata

from

birth

until2years

post-partum.

¶Atthetimepointofbirth,resultswerecorrectedformaternalpre-pregnancy

BMI,gestationalweightgain,pregnancy

duration,group,sexandmaternalglucose

tolerance

statusin

theadjusted

model.Atthelatertimepoints,resultswereadditionallyadjusted

forponderalindex

atbirth

andbreastfeedingstatus(fullybreastfed,partiallybreastfedorform

ula)at4monthspost-partum,

respectively.




In another recent study, maternal insulin resistance

during pregnancy, irrespective of glucose tolerance status,

emerged as a significant independent predictor of infant

weight gain and adiposity at 1 year of age measured by

skinfold thicknesses [4]. However, these findings might not

be directly comparable with our study because of differing

methodological approaches. It could thus be plausible that

measuring insulin resistance only in the fasting state as

HOMA-IR is not sensitive enough to detect associations

with infant adiposity or weight gain, compared with a more

complex assessment of insulin resistance under a glucose

challenge.

Besides markers of glucose metabolism, we further

assessed whether maternal triglyceride levels in later preg-

nancy are related to infant outcomes from birth until 2 years

post-partum. Increasing triglyceride concentrations over the

course of pregnancy are a characteristic feature of normal

pregnancy. Higher triglyceride levels in the maternal circu-

lation may enhance the concentration gradient across the

placenta, resulting in accelerated transport and deposition of

lipids in fetal tissues [27]. Against this theory, we could not

find any significant associations of maternal triglycerides

with neonatal body composition, apart from a weak

relationship between the change of maternal serum triglyc-

eride levels from 15th until the 32nd week of gestation and

subsequent ponderal index at 4 months. However, this slight

effect seems clinically irrelevant or might even have occurred

by chance with regard to the numerous correlations

explored. Thus, we could not confirm previous findings of

a small pilot study showing the increase in triglycerides from

early to late pregnancy to be highly predictive for neonatal

adiposity [28]. Other studies reported associations between

absolute maternal triglycerides levels and birthweight or

large-for-gestational-age infants [5,9,29]. Different sampling

time points, weight and health status of the women might

explain the discrepancy to our findings.

The strengths of our study are the extensive longitudinal

assessment of infant body composition over multiple time

points by two complementary methods from birth and

through the first 2 years of life and the collection of

biosamples both from the maternal and the fetal side. In

addition, we assessed a large set of maternal and child factors

related to infant adiposity to adjust for in the multivariate

analysis. However, although not the focus of this study, other

factors such as lifestyle in pregnancy, including physical

activity and diet, might influence the investigated associa-

tions through their effect on gestational weight gain or

birthweight [30]. A major limitation of our study is the

considerable loss to follow-up beyond the 1st year of life.

Although the individuals lost to follow-up were comparable

with the completers in their main characteristics, our results

might suggest a certain selection bias. Nevertheless, despite

the relatively small study population, it is intriguing that we

could still confirm sex-specific effects with regard to the

associations of fetal insulin with post-natal weight gain.

However, as no adjustments for multiple testing were made

within this rather exploratory approach, all significant

findings should be interpreted with caution. It should also

be acknowledged, that neither skinfold measurements nor

abdominal sonography represent direct methods for the

b: –8.99 [–15.65; –2.33] g, P = 0.010badj: –7.63 [–15.29; 0.03] g, P = 0.051

b: –6.47 [–18.60; 5.66] g, P = 0.289badj: –2.82 [–15.76; 10.11] g, P = 0.662

Girls (n = 39)

Boys (n = 54)

GirlsBoysGirlsBoys

Infant sex

FIGURE 1 Association of cord plasma insulin with infant weight gain up to 2 years post-partum stratified by gender. b, regression coefficient (95%

confidence interval) from linear regression analysis; badj, data adjusted for maternal pre-pregnancy BMI, gestational weight gain, pregnancy

duration, group, maternal glucose tolerance status, ponderal index at birth and mode of infant feeding at 4 months post-partum (fully breastfed,

partially breastfed or formula).



assessment of fat mass. Another limitation is that our study

protocol did not include a standardized glucose tolerance test

to assess insulin resistance under a glucose challenge, so that

we had to rely on measures of insulin resistance in the fasting

state. Furthermore, we did not measure other variables

related to fetal insulin secretion, such as C-peptide or

proinsulin, or lipids in umbilical cord blood, which might

also come into consideration as potential determinants of

fetal growth [7].

In conclusion, maternal insulin resistance and triglycerides

in the last trimester of pregnancy were only transiently

related to newborn/early post-natal infant growth and body

composition and did not emerge as major determinants for

infant weight development up to 2 years. In contrast, cord

blood insulin was highly correlated with birthweight and

newborn fat mass, and significantly inversely associated with

weight gain over the first 2 years of life in girls. This might

suggest a role for fetal insulin in programming energy

homeostasis in early life, which takes effect differently

between the sexes.

Funding sources

The study was funded by grants from the Else Kr€oner-Frese-

nius Foundation, Bad Homburg, Germany; the International

Unilever Foundation, Hamburg, Germany; the EU-funded

EARNEST consortium (FOOD-CT-2005-007036); and the

German Ministry of Education and Research via the

Competence Network on Obesity (Kompetenznetz Adipos-

itas, 01GI0842).

There was no intervention from any sponsor with any of

the research aspects of the study, including the study design,

intervention, data collection, analysis and interpretation, or

writing of the manuscript.

Competing interests

HH is on the Advisory Board for Weight Watchers Interna-

tional and has received grants from Riemser and Weight

Watchers for clinical trials and payment for lectures from

Novartis, Roche Germany, and Sanofi Aventis. All authors

declare that there is no duality of interest associated with this

manuscript.

Acknowledgements

We thank all the families who participated in the study. We

would like to thank the technical staff of the Institute of

Laboratory Medicine, Clinical Chemistry and Molecular

Diagnostics,University Hospital Leipzig, Leipzig, Germany

for assistance in performing the laboratory analyses. We

thank Petra Wolf (Institute for Medical Statistics and

Epidemiology, Klinikum rechts der Isar, Technische

Universit€at M€unchen, Munich, Germany) for statistical

support.

References

1 de Onis M, Blossner M, Borghi E. Global prevalence and trends of

overweight and obesity among preschool children. Am J Clin Nutr

2010; 92: 1257–1264.

2 Catalano PM, Thomas A, Huston-Presley L, Amini SB. Increased

fetal adiposity: a very sensitive marker of abnormal in utero

development. Am J Obstet Gynecol 2003; 189: 1698–1704.

3 HAPO Study Group. Hyperglycemia and Adverse Pregnancy

Outcome (HAPO) Study: associations with neonatal anthropomet-

rics. Diabetes 2009; 58: 453–459.

4 Hamilton JK, Odrobina E, Yin J, Hanley AJ, Zinman B, Retnak-

aran R. Maternal insulin sensitivity during pregnancy predicts

infant weight gain and adiposity at 1 year of age. Obesity (Silver

Spring) 2010; 18: 340–346.

5 Di Cianni G, Miccoli R, Volpe L, Lencioni C, Ghio A, Giovannitti

MG et al. Maternal triglyceride levels and newborn weight in

pregnant women with normal glucose tolerance. Diabet Med 2005;

22: 21–25.

6 Harmon KA, Gerard L, Jensen DR, Kealey EH, Hernandez TL,

Reece MS et al. Continuous glucose profiles in obese and

normal-weight pregnant women on a controlled diet: metabolic

determinants of fetal growth. Diabetes Care 2011; 34: 2198–

2204.

7 Schaefer-Graf UM, Graf K, Kulbacka I, Kjos SL, Dudenhausen J,

Vetter K et al. Maternal lipids as strong determinants of fetal

environment and growth in pregnancies with gestational diabetes

mellitus. Diabetes Care 2008; 31: 1858–1863.

8 Schaefer-Graf UM, Meitzner K, Ortega-Senovilla H, Graf K, Vetter

K, Abou-Dakn M et al. Differences in the implications of maternal

lipids on fetal metabolism and growth between gestational diabetes

mellitus and control pregnancies. Diabet Med 2011; 28:

1053–1059.

9 Misra VK, Trudeau S, Perni U. Maternal serum lipids during

pregnancy and infant birthweight: the influence of prepregnancy

BMI. Obesity (Silver Spring) 2011; 19: 1476–1481.

10 Ong K, Kratzsch J, Kiess W, Costello M, Scott C, Dunger D. Size at

birth and cord blood levels of insulin, insulin-like growth factor I

(IGF-I), IGF-II, IGF-binding protein-1 (IGFBP-1), IGFBP-3, and the

soluble IGF-II/mannose-6-phosphate receptor in term human

infants. The ALSPAC Study Team. Avon Longitudinal Study of

Pregnancy and Childhood. J Clin Endocrinol Metab 2000; 85:

4266–4269.

11 Ong KK, Ahmed ML, Sherriff A, Woods KA, Watts A, Golding J et

al. Cord blood leptin is associated with size at birth and predicts

infancy weight gain in humans. ALSPAC Study Team. Avon

Longitudinal Study of Pregnancy and Childhood. J Clin Endocrinol

Metab 1999; 84: 1145–1148.

12 Tsai PJ, Yu CH, Hsu SP, Lee YH, Chiou CH, Hsu YW et al. Cord

plasma concentrations of adiponectin and leptin in healthy term

neonates: positive correlation with birthweight and neonatal

adiposity. Clin Endocrinol (Oxf) 2004; 61: 88–93.

13 Pettitt DJ, McKenna S, McLaughlin C, Patterson CC, Hadden DR,

McCance DR. Maternal glucose at 28 weeks of gestation is not

associated with obesity in 2-year-old offspring: the Belfast Hyper-

glycemia and Adverse Pregnancy Outcome (HAPO) family study.

Diabetes Care 2010; 33: 1219–1223.

14 Regnault N, Botton J, Heude B, Forhan A, Hankard R, Foliguet B

et al. Higher cord C-peptide concentrations are associated with

slower growth rate in the 1st year of life in girls but not in boys.

Diabetes 2011; 60: 2152–2159.

15 Shields BM, Knight B, Hopper H, Hill A, Powell RJ, Hattersley AT

et al. Measurement of cord insulin and insulin-related peptides

suggests that girls are more insulin resistant than boys at birth.

Diabetes Care 2007; 30: 2661–2666.




16 Hauner H, Much D, Vollhardt C, Brunner S, Schmid D, Sedlmeier

EM et al. Effect of reducing the n-6:n-3 long-chain PUFA ratio

during pregnancy and lactation on infant adipose tissue growth

within the first year of life: an open-label randomized controlled

trial. Am J Clin Nutr 2012; 95: 383–394.

17 Hauner H, Vollhardt C, Schneider KT, Zimmermann A, Schuster

T, Amann-Gassner U. The impact of nutritional fatty acids during

pregnancy and lactation on early human adipose tissue develop-

ment. Rationale and design of the INFAT study. Ann Nutr Metab

2009; 54: 97–103.

18 Coustan DR, Lowe LP, Metzger BE, Dyer AR. International

Association of Diabetes and Pregnancy Study Groups. The Hyper-

glycemia and Adverse Pregnancy Outcome (HAPO) study: paving

the way for new diagnostic criteria for gestational diabetes mellitus.

Am J Obstet Gynecol 2010; 202: e651–e656.

19 Weststrate JA, Deurenberg P. Body composition in children:

proposal for a method for calculating body fat percentage from

total body density or skinfold-thickness measurements. Am J Clin

Nutr 1989; 50: 1104–1115.

20 Holzhauer S, Zwijsen RM, Jaddoe VW, Boehm G, Moll HA,

Mulder PG et al. Sonographic assessment of abdominal fat

distribution in infancy. Eur J Epidemiol 2009; 24: 521–529.

21 Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF,

Turner RC. Homeostasis model assessment: insulin resistance and

beta-cell function from fasting plasma glucose and insulin concen-

trations in man. Diabetologia 1985; 28: 412–419.

22 Wilkin TJ, Murphy MJ. The gender insulin hypothesis: why girls

are born lighter than boys, and the implications for insulin

resistance. Int J Obes (Lond) 2006; 30: 1056–1061.

23 Murphy MJ, Metcalf BS, Voss LD, Jeffery AN, Kirkby J, Mallam

KM et al. Girls at five are intrinsically more insulin resistant than

boys: The Programming Hypotheses Revisited—The EarlyBird

Study (EarlyBird 6). Pediatrics 2004; 113: 82–86.

24 Bhargava SK, Sachdev HS, Fall CH, Osmond C, Lakshmy R,

Barker DJ et al. Relation of serial changes in childhood body mass

index to impaired glucose tolerance in young adulthood. N Engl J

Med 2004; 350: 865–875.

25 Barker DJ, Osmond C, Forsen TJ, Kajantie E, Eriksson JG.

Trajectories of growth among children who have coronary events

as adults. N Engl J Med 2005; 353: 1802–1809.

26 Parker M, Rifas-Shiman SL, Belfort MB, Taveras EM, Oken E,

Mantzoros C et al. Gestational glucose tolerance and cord blood

leptin levels predict slower weight gain in early infancy. J Pediatr

2011; 158: 227–233.

27 Heerwagen MJ, Miller MR, Barbour LA, Friedman JE. Maternal

obesity and fetal metabolic programming: a fertile epigenetic soil.

Am J Physiol Regul Integr Comp Physiol 2010; 299: R711–722.

28 Barbour LA, Hernandez TL, Reece MS, Horton TJ, Kahn BF,

Nadeau KJ et al. Change in fasting triglycerides from early to late

gestation is highly predictive of neonatal adiposity. Diabetes 2009;

58: A84.

29 Vrijkotte TG, Krukziener N, Hutten BA, Vollebregt KC, van

Eijsden M, Twickler MB. Maternal lipid profile during early

pregnancy and pregnancy complications and outcomes: The ABCD

Study. J Clin Endocrinol Metab 2012; 97: 3917–3925.

30 Thangaratinam S, Rogozinska E, Jolly K, Glinkowski S, Roseboom

T, Tomlinson JW et al. Effects of interventions in pregnancy on

maternal weight and obstetric outcomes: meta-analysis of rando-

mised evidence. Br Med J 2012; 344: e2088.

Supporting Information

Additional Supporting Information may be found in the

online version of this article:

Table S1. Maternal insulin and HOMA-IR measured at the

32nd week of gestation in relation to infant outcomes up to

2 years post-partum.

Table S2.Maternal triglycerides at the 32ndweek of gestation

and change in triglycerides from the 15th week until the 32nd

week of gestation in relation to infant outcomes up to 2 years

post-partum.



maternal insulin resistance, triglycerides and cord blood insulin in relation to post-natal weight...

Documents