Maternal diabetes during pregnancy and early onset of cardiovascular disease in offspring: population based cohort study with 40 years of follow-upBMJ 2019; 367 doi: https://doi.org/10.1136/bmj.l6398 (Published 04 December 2019) Cite this as: BMJ 2019;367:l6398
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On the associations between maternal diabetes during pregnancy and early onset cardiovascular disease in offspring
Jia-shuo Liu*, Zhou Xu*, Shen Tian, Juan Wu, Ling-quan Kong
* These authors have contributed equally to this work.
Department of Endocrine and Breast Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
Dr. Ling-quan Kong, Department of Endocrine and Breast Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China. E-mail: firstname.lastname@example.org Tel:+8613101380893
Yu and colleagues reported that maternal diabetes during pregnancy was associated with an increased rate of early onset cardiovascular disease (CVD) among offspring across the first four decades of life, especially for the offspring of those mothers with a history of CVD or diabetic complications. Then the authors concluded that preventing, screening, and treatment of diabetes in women of childbearing age could help to reduce the risk of CVD in the next generation. However, we think this might be misleading and suggest the following problems in their study should be resolved to help better understand the result and make more convincing conclusion.
First, the study was initiated in 1977, long before the release of current WHO/ADA diabetes criteria and IADPSG/ADA/WHO gestational diabetes criteria. Compared with that in 1985 WHO diabetes criteria, in the current 1999 WHO/1997 ADA diabetes criteria, the cut-off point of fasting plasma glucose (FPG) has been adapted from <7.8 mmol/L to <7.0 mmol/L. The original participants with an FPG of 7.0 mmol/L to less than 7.8 mmol/L would be diagnosed with diabetes according to the current criteria. Furthermore, the current 2010 IADPSG gestational diabetes criteria has also significantly changed from the outdated criteria. During the 40-year follow-up (1977-2016) in this study, the update of diagnostic and inclusion criteria in clinical trials should not be ignored. Thus, these results should be interpreted more cautiously by stratified analysis according to the outdated and current diagnostic criteria, respectively.
Second, birth weight has been shown to be influenced by both fetal and maternal factors and, as proved in observational studies, both low and high birth weight are reproducibly associated with increased risks of type 2 diabetes and cardiovascular disease in later life.[5, 6] However in this study, birth weight was not included during analysis, though its information is available from the Danish Medical Birth Registry. In addition, previous epidemiological studies have shown that maternal obesity during pregnancy (maternal body mass index (BMI) measured at the first antenatal visit) is associated with increased hazard of type 2 diabetes and cardiovascular disease in offspring. Whereas, maternal pre-pregnancy BMI instead of maternal BMI during pregnancy or gestational weight gain was performed in stratified analysis in this study, which might exist some limitations. Therefore, further subgroup analysis including the above mentioned factors should be considered and investigated in a more scientifically serious way.
 Yu Y, Arah OA, Liew Z, Cnattingius S, Olsen J, Sorensen HT, et al. Maternal diabetes during pregnancy and early onset of cardiovascular disease in offspring: population based cohort study with 40 years of follow-up. BMJ. 2019;367:l6398.
 WHO, International Diabetes Federation. Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia: report of a WHO/IDF consultation. Geneva: World Health Organization, 2006.
 Metzger BE, Gabbe SG, Persson B, Buchanan TA, Catalano PA, Damm P, et al. International association of diabetes and pregnancy study groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes care. 2010;33:676-82.
 Li H, Tian S, Wu J, Xu Z, Kong LQ. Diagnostic criteria should be considered when reviewing the effect of diabetes prevention studies. Diabetologia. 2019;62:2163-5.
 Whincup PH, Kaye SJ, Owen CG, Huxley R, Cook DG, Anazawa S, et al. Birth weight and risk of type 2 diabetes: a systematic review. Jama. 2008;300:2886-97.
 Gluckman PD, Hanson MA, Cooper C, Thornburg KL. Effect of in utero and early-life conditions on adult health and disease. The New England journal of medicine. 2008;359:61-73.
 Lahti-Pulkkinen M, Bhattacharya S, Wild SH, Lindsay RS, Raikkonen K, Norman JE, et al. Consequences of being overweight or obese during pregnancy on diabetes in the offspring: a record linkage study in Aberdeen, Scotland. Diabetologia. 2019;62:1412-9.
 Reynolds RM, Allan KM, Raja EA, Bhattacharya S, McNeill G, Hannaford PC, et al. Maternal obesity during pregnancy and premature mortality from cardiovascular event in adult offspring: follow-up of 1 323 275 person years. BMJ. 2013;347:f4539.
Competing interests: No competing interests
Mothers with diabetes got diabetes by killing their pancreatic beta cells by stressing them with lots of carbs (dietary glucose).
Mothers with heart disease got heart disease by eating lots of carbs (bad, glucose) and sugar (worse, fructose) causing their livers to produce VLDLs which caused small, dense LDLs which penetrated their artery walls, eventuating in arterial plaque.
These mothers who ate high carb, high sugar diets fed their kids high carb, high sugar diets and taught their kids to feed themselves (and their kids) high carb, high sugar diets.
It’s cultural epidemiology.
Competing interests: No competing interests