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\title{Re: Maternal lipids are associated with newborn adiposity independent of
GDM status, obesity and insulin resistance: a prospective observational
cohort study. (First comment on BJOG-19-0616.R2)}



\author[1]{Ellis Muggleton}%
\author[1]{Tuelin Muggleton}%
\affil[1]{Klinikum rechts der Isar der Technischen Universität München}%


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  \date{June 07, 2024}


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Letter to the Editor, BJOG Exchange

\textbf{Re: Maternal lipids are associated with newborn adiposity
independent of GDM status, obesity and insulin resistance: a prospective
observational cohort study}

{[}Authors` title{]} High carbohydrate Intake Influences Foetal
Development

Whilst welcoming research into the metabolic influences on fetal
development and birth, we do not agree with the conclusions of Samsuddin
et al\textsuperscript{1} that maternal lipaemia and GWG at a low
threshold adversely impact neonatal adiposity``. This is, in our
opinion, an incorrect interpretation of the physiological processes
involved.

Although the study did demonstrate an association of triglyceride levels
with large-for-gestational age, this is an association and not a
causative relationship. Serum triglycerides are largely dependent on
diet. This phenomenon, known as carbohydrate-induced
hypertriglyceridaemia (HPTG) has been well described\textsuperscript{2}.
Given the high carbohydrate content of the malaysian diet, the
carbohydrate intake in these patients is likely both the cause of the
elevated triglyceride levels and the subsequent weight gain.
High-carbohydrate diets also lead to increased synthesis of fatty
acids\textsuperscript{3}. The insulin sensitivity need not necessarily
be reduced in this group but the total exposure to insulin (in effect
the area under the curve) will be increased leading to, amongst other
effects, excess growth.

Insulin sensitvity was reduced in the gestational diabetes group and in
the obese group with normal glucose tolerance in comparison to the
non-obese group with normal glucose tolerance. This is to be expected;
obesity and high carbohydrate intake will, however, eventually lead to
increased IR.

The authors focus on the role of maternal lipaemia on subsequent
generations. However, insulin has been demonstrated to significantly
influence placental development. Total exposure to Insulin is increased
in patients consuming a high carbohydrate diet. Fetal insulin has been
shown to bind to fetal endothelium and alter the expression of several
genes involved in metabolism\textsuperscript{4}. These changes are more
likely to alter the cardiovascular risk of the foetuses in adult age.

It is our interpretation of the data that high carbohydrate nutrition is
the modifiable risk-factor that needs addressing. Reduction in
carbohydrate intake would lead to less significant weight gain, less
insulin resistance and less exposure to insulin. This would allow an
improvement in placental function and less endothelial damage in the
foetus.

Ellis Muggleton and T\selectlanguage{ngerman}ülin Muggleton

Department of Anesthesiology and Intensive Care Medicine

Klinikum rechts der Isar

Technical University of Munich

REFERENCES

Samsuddin S, Arumugam PA et al. Maternal lipids are associated with
newborn adiposity independent of GDM status, obesity and insulin
resistance: a prospective observational cohort study. BJOG. DOI
10.1111/1471-0528.16031

Parks E.J. Effect of Dietary Carbohydrate on Triglyceride Metabolism in
Humans. The Journal of Nutrition 131(10): 2772S-2774S, 2001.

Hudgins LC. Effect of high-carbohydrate feeding on troglyceride and
saturated fatty acid synthesis. Proc Soc Exp Biol Med 2000 Dec; 225 (3):
178-83.

Ruiz-Palacios M, Ruiz-Alcaraz AJ et al. Role of Insulin in Placental
Transport in Gestational Diabetes Mellitus. Ann Nutr Metab 2017; 70:
16-25.

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