Cord blood metabolites and rapid postnatal growth as multiple mediators in the prenatal propensity to childhood overweight.


Journal

International journal of obesity (2005)
ISSN: 1476-5497
Titre abrégé: Int J Obes (Lond)
Pays: England
ID NLM: 101256108

Informations de publication

Date de publication:
07 2022
Historique:
received: 10 09 2021
accepted: 23 02 2022
revised: 22 02 2022
pubmed: 5 5 2022
medline: 1 7 2022
entrez: 4 5 2022
Statut: ppublish

Résumé

The mechanisms underlying childhood overweight and obesity are poorly known. Here, we investigated the direct and indirect effects of different prenatal exposures on offspring rapid postnatal growth and overweight in childhood, mediated through cord blood metabolites. Additionally, rapid postnatal growth was considered a potential mediator on childhood overweight, alone and sequentially to each metabolite. Within four European birth-cohorts (N = 375 mother-child dyads), information on seven prenatal exposures (maternal education, pre-pregnancy BMI, weight gain and tobacco smoke during pregnancy, age at delivery, parity, and child gestational age), selected as obesogenic according to a-priori knowledge, was collected. Cord blood levels of 31 metabolites, associated with rapid postnatal growth and/or childhood overweight in a previous study, were measured via liquid-chromatography-quadrupole-time-of-flight-mass-spectrometry. Rapid growth at 12 months and childhood overweight (including obesity) between four and eight years were defined with reference to WHO growth charts. Single mediation analysis was performed using the imputation approach and multiple mediation analysis using the extended-imputation approach. Single mediation suggested that the effect of maternal education, pregnancy weight gain, parity, and gestational age on rapid postnatal growth but not on childhood overweight was partly mediated by seven metabolites, including cholestenone, decenoylcarnitine(C10:1), phosphatidylcholine(C34:3), progesterone and three unidentified metabolites; and the effect of gestational age on childhood overweight was mainly mediated by rapid postnatal growth. Multiple mediation suggested that the effect of gestational age on childhood overweight was mainly mediated by rapid postnatal growth and that the mediating role of the metabolites was marginal. Our findings provide evidence of the involvement of in utero metabolism in the propensity to rapid postnatal growth and of rapid postnatal growth in the propensity to childhood overweight. We did not find evidence supporting a mediating role of the studied metabolites alone between the studied prenatal exposures and the propensity to childhood overweight.

Sections du résumé

BACKGROUND
The mechanisms underlying childhood overweight and obesity are poorly known. Here, we investigated the direct and indirect effects of different prenatal exposures on offspring rapid postnatal growth and overweight in childhood, mediated through cord blood metabolites. Additionally, rapid postnatal growth was considered a potential mediator on childhood overweight, alone and sequentially to each metabolite.
METHODS
Within four European birth-cohorts (N = 375 mother-child dyads), information on seven prenatal exposures (maternal education, pre-pregnancy BMI, weight gain and tobacco smoke during pregnancy, age at delivery, parity, and child gestational age), selected as obesogenic according to a-priori knowledge, was collected. Cord blood levels of 31 metabolites, associated with rapid postnatal growth and/or childhood overweight in a previous study, were measured via liquid-chromatography-quadrupole-time-of-flight-mass-spectrometry. Rapid growth at 12 months and childhood overweight (including obesity) between four and eight years were defined with reference to WHO growth charts. Single mediation analysis was performed using the imputation approach and multiple mediation analysis using the extended-imputation approach.
RESULTS
Single mediation suggested that the effect of maternal education, pregnancy weight gain, parity, and gestational age on rapid postnatal growth but not on childhood overweight was partly mediated by seven metabolites, including cholestenone, decenoylcarnitine(C10:1), phosphatidylcholine(C34:3), progesterone and three unidentified metabolites; and the effect of gestational age on childhood overweight was mainly mediated by rapid postnatal growth. Multiple mediation suggested that the effect of gestational age on childhood overweight was mainly mediated by rapid postnatal growth and that the mediating role of the metabolites was marginal.
CONCLUSION
Our findings provide evidence of the involvement of in utero metabolism in the propensity to rapid postnatal growth and of rapid postnatal growth in the propensity to childhood overweight. We did not find evidence supporting a mediating role of the studied metabolites alone between the studied prenatal exposures and the propensity to childhood overweight.

Identifiants

pubmed: 35508813
doi: 10.1038/s41366-022-01108-0
pii: 10.1038/s41366-022-01108-0
pmc: PMC9239910
doi:

Types de publication

Journal Article Research Support, Non-U.S. Gov't

Langues

eng

Sous-ensembles de citation

IM

Pagination

1384-1393

Subventions

Organisme : Medical Research Council
ID : MR/S03532X/1
Pays : United Kingdom

Informations de copyright

© 2022. The Author(s).

Références

NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet. 2017;390:2627–42.
Singh AS, Mulder C, Twisk JW, van Mechelen W, Chinapaw MJ. Tracking of childhood overweight into adulthood: a systematic review of the literature. Obes Rev. 2008;9:474–88.
pubmed: 18331423 doi: 10.1111/j.1467-789X.2008.00475.x
Bendor CD, Bardugo A, Pinhas-Hamiel O, Afek A, Twig G. Cardiovascular morbidity, diabetes and cancer risk among children and adolescents with severe obesity. Cardiovasc Diabetol. 2020;19:79.
pubmed: 32534575 pmcid: 7293793 doi: 10.1186/s12933-020-01052-1
Simmonds M, Llewellyn A, Owen CG, Woolacott N. Predicting adult obesity from childhood obesity: a systematic review and meta-analysis. Obes Rev. 2016;17:95–107.
pubmed: 26696565 doi: 10.1111/obr.12334
Gahagan S, Uauy R, Roseboom TJ. Developmental origins of pediatric obesity. Int J Pediatrics. 2012;2012:309863.
doi: 10.1155/2012/309863
Silventoinen K, Rokholm B, Kaprio J, Sørensen TI. The genetic and environmental influences on childhood obesity: a systematic review of twin and adoption studies. Int J Obes. 2010;34:29–40.
doi: 10.1038/ijo.2009.177
Hales CN, Barker DJP. The thrifty phenotype hypothesis: type 2 diabetes. Br Med Bul. 2001;60:5–20.
doi: 10.1093/bmb/60.1.5
Morgen CS, Ängquist L, Baker JL, Andersen AMN, Michaelsen KF, Sørensen TIA. Prenatal risk factors influencing childhood BMI and overweight independent of birth weight and infancy BMI: a path analysis within the Danish National Birth Cohort. Int J Obes. 2018;42:594–602.
doi: 10.1038/ijo.2017.217
Lamerz A, Kuepper-Nybelen J, Wehle C, Bruning N, Trost-Brinkhues G, Brenner H, et al. Social class, parental education, and obesity prevalence in a study of six-year-old children in Germany. Int J Obes. 2005;29:373–80.
doi: 10.1038/sj.ijo.0802914
Voerman E, Santos S, Patro Golab B, Amiano P, Ballester F, Barros H, et al. Maternal body mass index, gestational weight gain, and the risk of overweight and obesity across childhood: An individual participant data meta-analysis. PLoS Med. 2019;16:e1002744.
pubmed: 30742624 pmcid: 6370184 doi: 10.1371/journal.pmed.1002744
Liu S, Lei J, Ma J, Ma Y, Wang S, Yuan Y, et al. Interaction between delivery mode and maternal age in predicting overweight and obesity in 1,123 Chinese preschool children. Ann Transl Med. 2020;8:474–474.
pubmed: 32395518 pmcid: 7210148 doi: 10.21037/atm.2020.03.128
Heslehurst N, Vieira R, Akhter Z, Bailey H, Slack E, Ngongalah L, et al. The association between maternal body mass index and child obesity: A systematic review and meta-analysis. PLoS Med. 2019;16:e1002817.
pubmed: 31185012 pmcid: 6559702 doi: 10.1371/journal.pmed.1002817
Gaillard R, Rurangirwa AA, Williams MA, Hofman A, Mackenbach JP, Franco OH, et al. Maternal parity, fetal and childhood growth, and cardiometabolic risk factors. Hypertension. 2014;64:266–74.
pubmed: 24866145 doi: 10.1161/HYPERTENSIONAHA.114.03492
Ou-Yang MC, Sun Y, Liebowitz M, Chen CC, Fang ML, Dai W, et al. Accelerated weight gain, prematurity, and the risk of childhood obesity: A meta-analysis and systematic review. PLoS One. 2020;15:e0232238.
pubmed: 32369502 pmcid: 7199955 doi: 10.1371/journal.pone.0232238
von Kries R, Toschke AM, Koletzko B, Slikker W Jr. Maternal smoking during pregnancy and childhood obesity. Am J Epidemiol. 2002;156:954–61.
doi: 10.1093/aje/kwf128
Rolle-Kampczyk UE, Krumsiek J, Otto W, Röder SW, Kohajda T, Borte M, et al. Metabolomics reveals effects of maternal smoking on endogenous metabolites from lipid metabolism in cord blood of newborns. Metabolomics. 2016;12:76–76.
pubmed: 27065762 pmcid: 4783445 doi: 10.1007/s11306-016-0983-z
Lowe WL Jr., Bain JR, Nodzenski M, Reisetter AC, Muehlbauer MJ, Stevens RD, et al. Maternal BMI and Glycemia Impact the Fetal Metabolome. Diabetes Care. 2017;40:902–10.
pubmed: 28637888 pmcid: 5481987 doi: 10.2337/dc16-2452
Handakas E, Keski-Rahkonen P, Chatzi L, Alfano R, Roumeliotaki T, Plusquin M, et al. Cord blood metabolic signatures predictive of childhood overweight and rapid growth. Int J Obes. 2021;45:2252–60.
doi: 10.1038/s41366-021-00888-1
Zheng M, Lamb KE, Grimes C, Laws R, Bolton K, Ong KK, et al. Rapid weight gain during infancy and subsequent adiposity: a systematic review and meta-analysis of evidence. Obes Rev. 2018;19:321–32.
pubmed: 29052309 doi: 10.1111/obr.12632
Janssen BG, Madhloum N, Gyselaers W, Bijnens E, Clemente DB, Cox B, et al. Cohort Profile: the ENVIRonmental influence ON early AGEing (ENVIRONAGE): a birth cohort study. Int J Epidemiol. 2017;46:1386–1387m.
pubmed: 28089960 doi: 10.1093/ije/dyx033
Guxens M, Ballester F, Espada M, Fernandez MF, Grimalt JO, Ibarluzea J, et al. Cohort Profile: the INMA–INfancia y Medio Ambiente–(Environment and Childhood) Project. Int J Epidemiol. 2012;41:930–40.
pubmed: 21471022 doi: 10.1093/ije/dyr054
Farchi S, Forastiere F, Vecchi Brumatti L, Alviti S, Arnofi A, Bernardini T, et al. Piccolipiu, a multicenter birth cohort in Italy: protocol of the study. BMC Pediatr. 2014;14:36.
pubmed: 24506846 pmcid: 3926689 doi: 10.1186/1471-2431-14-36
Chatzi L, Plana E, Daraki V, Karakosta P, Alegkakis D, Tsatsanis C, et al. Metabolic syndrome in early pregnancy and risk of preterm birth. Am J Epidemiol. 2009;170:829–36.
pubmed: 19713286 doi: 10.1093/aje/kwp211
Chatzi L, Leventakou V, Vafeiadi M, Koutra K, Roumeliotaki T, Chalkiadaki G, et al. Cohort profile: the mother-child cohort in Crete, Greece (Rhea Study). Int J Epidemiol. 2017;46:1392–1393k.
pubmed: 29040580 doi: 10.1093/ije/dyx084
Vineis P, Chadeau-Hyam M, Gmuender H, Gulliver J, Herceg Z, Kleinjans J, et al. The exposome in practice: design of the EXPOsOMICS project. Int J Hyg Environ Health. 2017;220:142–51.
pubmed: 27576363 pmcid: 6192011 doi: 10.1016/j.ijheh.2016.08.001
Robinson O, Keski-Rahkonen P, Chatzi L, Kogevinas M, Nawrot T, Pizzi C, et al. Cord blood metabolic signatures of birth weight: a population-based study. J Proteome Res. 2018;17:1235–47.
pubmed: 29401400 doi: 10.1021/acs.jproteome.7b00846
Sumner LW, Amberg A, Barrett D, Beale MH, Beger R, Daykin CA, et al. Proposed minimum reporting standards for chemical analysis Chemical Analysis Working Group (CAWG) Metabolomics Standards Initiative (MSI). Metabolomics. 2007;3:211–21.
pubmed: 24039616 pmcid: 3772505 doi: 10.1007/s11306-007-0082-2
Ong KK, Ahmed ML, Emmett PM, Preece MA, Dunger DB. Association between postnatal catch-up growth and obesity in childhood: prospective cohort study. BMJ. 2000;320:967–71.
pubmed: 10753147 pmcid: 27335 doi: 10.1136/bmj.320.7240.967
WHO Child Growth Standards. Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: Methods and development. Geneva: World Health Organization; 2006.
Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ. 2000;320:1240–3.
pubmed: 10797032 pmcid: 27365 doi: 10.1136/bmj.320.7244.1240
Vansteelandt S, Bekaert M, Lange T. Imputation strategies for the estimation of natural direct and indirect effects. Epidemiol Methods. 2012;1:131–58.
Steen J, Loeys T, Moerkerke B, Vansteelandt S. Flexible mediation analysis with multiple mediators. Am J Epidemiol. 2017;186:184–93.
pubmed: 28472328 doi: 10.1093/aje/kwx051
Dulloo AG, Jacquet J, Seydoux J, Montani JP. The thrifty ‘catch-up fat’ phenotype: its impact on insulin sensitivity during growth trajectories to obesity and metabolic syndrome. Int J Obes. 2006;30:S23–S35.
doi: 10.1038/sj.ijo.0803516
Kenny DJ, Plichta DR, Shungin D, Koppel N, Hall AB, Fu B, et al. Cholesterol metabolism by uncultured human gut bacteria Influences Host cholesterol level. Cell Host Microbe. 2020;28:245–57. e6
pubmed: 32544460 pmcid: 7435688 doi: 10.1016/j.chom.2020.05.013
Mukherjee A, Lordan C, Ross RP, Cotter PD. Gut microbes from the phylogenetically diverse genus Eubacterium and their various contributions to gut health. Gut Microbes. 2020;12:1802866.
pubmed: 32835590 pmcid: 7524325 doi: 10.1080/19490976.2020.1802866
Ernst M, Rogers S, Lausten-Thomsen U, Björkbom A, Laursen SS, Courraud J, et al. Gestational age-dependent development of the neonatal metabolome. Pediatr Res. 2021;89:1396–404.
pubmed: 32942288 doi: 10.1038/s41390-020-01149-z
Alfano R, Chadeau-Hyam M, Ghantous A, Keski-Rahkonen P, Chatzi L, Perez AE, et al. A multi-omic analysis of birthweight in newborn cord blood reveals new underlying mechanisms related to cholesterol metabolism. Metabolism. 2020;110:154292.
pubmed: 32553738 pmcid: 7450273 doi: 10.1016/j.metabol.2020.154292
Cao T, Zhao J, Hong X, Wang G, Hu FB, Wang X, et al. Cord blood metabolome and BMI trajectory from birth to adolescence: a prospective birth cohort study on early life biomarkers of persistent obesity. Metabolites. 2021;11:739.
pubmed: 34822398 pmcid: 8625562 doi: 10.3390/metabo11110739
Handakas E, Lau CH, Alfano R, Chatzi VL, Plusquin M, Vineis P, et al. A systematic review of metabolomic studies of childhood obesity: State of the evidence for metabolic determinants and consequences. Obes Rev 2021;23 Suppl 1:e13384.
Vidarsdottir H, Halldorsson TI, Geirsson RT, Bjarnason R, Franzson L, Valdimarsdottir UA, et al. Mode of delivery was associated with transient changes in the metabolomic profile of neonates. Acta Paediatr. 2021;110:2110–8.
pubmed: 33636029 doi: 10.1111/apa.15822
Darst BF, Koscik RL, Hogan KJ, Johnson SC, Engelman CD. Longitudinal plasma metabolomics of aging and sex. Aging. 2019;11:1262–82.
pubmed: 30799310 pmcid: 6402508 doi: 10.18632/aging.101837
Rhee KE, Phelan S, McCaffery J. Early determinants of obesity: genetic, epigenetic, and in utero influences. Int J Pediatrics. 2012;2012:463850.
doi: 10.1155/2012/463850
Czyzyk A, Podfigurna A, Genazzani AR, Meczekalski B. The role of progesterone therapy in early pregnancy: from physiological role to therapeutic utility. Gynecol Endocrinol. 2017;33:421–4.
pubmed: 28277122 doi: 10.1080/09513590.2017.1291615
Barrett ES, Parlett LE, Windham GC, Swan SH. Differences in ovarian hormones in relation to parity and time since last birth. Fertil Steril. 2014;101:1773–80.e1.
pubmed: 24684956 pmcid: 4041832 doi: 10.1016/j.fertnstert.2014.02.047
Maccoby EE, Doering CH, Jacklin CN, Kraemer H. Concentrations of sex hormones in umbilical-cord blood: their relation to sex and birth order of infants. Child Dev. 1979;50:632–42.
pubmed: 498842 doi: 10.2307/1128928
Ong KK, Preece MA, Emmett PM, Ahmed ML, Dunger DB. Size at birth and early childhood growth in relation to maternal smoking, parity and infant breast-feeding: longitudinal birth cohort study and analysis. Pediatr Res. 2002;52:863–7.
pubmed: 12438662 doi: 10.1203/00006450-200212000-00009
Ross AB, Barman M, Hartvigsson O, Lundell AC, Savolainen O, Hesselmar B, et al. Umbilical cord blood metabolome differs in relation to delivery mode, birth order and sex, maternal diet and possibly future allergy development in rural children. PLoS ONE. 2021;16:e0242978.
pubmed: 33493154 pmcid: 7833224 doi: 10.1371/journal.pone.0242978
Van Den Berg G, Van Eijsden M, Galindo-Garre F, Vrijkotte T, Gemke R. Low maternal education is associated with increased growth velocity in the first year of life and in early childhood: the ABCD study. Eur J Pediatr. 2013;172:1451–7.
doi: 10.1007/s00431-013-2063-y
Wang L, van Grieken A, Yang-Huang J, Vlasblom E, L’Hoir MP, Boere-Boonekamp MM, et al. Relationship between socioeconomic status and weight gain during infancy: The BeeBOFT study. PLoS ONE. 2018;13:e0205734.
pubmed: 30388128 pmcid: 6214496 doi: 10.1371/journal.pone.0205734
Robinson O, Carter AR, Ala-Korpela M, Casas JP, Chaturvedi N, Engmann J, et al. Metabolic profiles of socio-economic position: a multi-cohort analysis. Int J Epidemiol. 2020;50:768–82.
pmcid: 8271201 doi: 10.1093/ije/dyaa188
Ye S, Zhong J, Huang J, Zhang S, Li H, Chen D, et al. (+)4-Cholesten-3-one promotes differentiation of neural stem cells into dopaminergic neurons through TET1 and FoxA2. Neurosci Lett. 2020;735:135239.
pubmed: 32650052 doi: 10.1016/j.neulet.2020.135239
Guennoun R. Progesterone in the brain: hormone, neurosteroid and neuroprotectant. Int J Mol Sci. 2020;21:5271.
pmcid: 7432434 doi: 10.3390/ijms21155271
Stevens DR, Neelon B, Roberts JR, Taylor SN, Newman RB, Vena JE, et al. Mediation of the association between maternal pre-pregnancy overweight/obesity and childhood overweight/obesity by birth anthropometry. J Dev Orig Health Dis. 2020;12:71–8.
pubmed: 32077839 pmcid: 7438242 doi: 10.1017/S2040174420000033
Salahuddin M, Pérez A, Ranjit N, Hoelscher DM, Kelder SH. The effect of prenatal maternal cigarette smoking on children’s BMI z-score with SGA as a mediator. Int J Obes. 2018;42:1008–18.
doi: 10.1038/s41366-018-0038-9
Freedman DS, Wang J, Maynard LM, Thornton JC, Mei Z, Pierson RN, et al. Relation of BMI to fat and fat-free mass among children and adolescents. Int J Obes. 2005;29:1–8.
doi: 10.1038/sj.ijo.0802735
Hernán MA. Causal analyses of existing databases: no power calculations required. J Clin Epidemiol. 2022;144:203–5.
pubmed: 34461211 doi: 10.1016/j.jclinepi.2021.08.028
Sharp GC, Lawlor DA, Richardson SS. It’s the mother!: How assumptions about the causal primacy of maternal effects influence research on the developmental origins of health and disease. Soc Sci Med. 2018;213:20–7.
pubmed: 30055422 pmcid: 6137073 doi: 10.1016/j.socscimed.2018.07.035
Davison KK, Gicevic S, Aftosmes-Tobio A, Ganter C, Simon CL, Newlan S, et al. Fathers’ representation in observational studies on parenting and childhood obesity: a systematic review and content analysis. Am J Public Health. 2016;106:e14–e21.
pubmed: 27631735 pmcid: 5055776 doi: 10.2105/AJPH.2016.303391
Lee S, Gulseth HL, Langleite TM, Norheim F, Olsen T, Refsum H, et al. Branched-chain amino acid metabolism, insulin sensitivity and liver fat response to exercise training in sedentary dysglycaemic and normoglycaemic men. Diabetologia. 2021;64:410–23.
pubmed: 33123769 doi: 10.1007/s00125-020-05296-0

Auteurs

Rossella Alfano (R)

Centre for Environmental Sciences, Hasselt University, Diepenbeek, Belgium. rossella.alfano@uhasselt.be.
Μedical Research Council-Health Protection Agency Centre for Environment and Health, Imperial College London, London, UK. rossella.alfano@uhasselt.be.

Michelle Plusquin (M)

Centre for Environmental Sciences, Hasselt University, Diepenbeek, Belgium.

Oliver Robinson (O)

Μedical Research Council-Health Protection Agency Centre for Environment and Health, Imperial College London, London, UK.

Sonia Brescianini (S)

Centre for Behavioural Science and Mental Health, Istituto Superiore di Sanità, Rome, Italy.

Lida Chatzi (L)

Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, USA.

Pekka Keski-Rahkonen (P)

Nutrition and Metabolism Branch, International Agency for Research on Cancer, Lyon, France.

Evangelos Handakas (E)

Μedical Research Council-Health Protection Agency Centre for Environment and Health, Imperial College London, London, UK.

Lea Maitre (L)

Barcelona Institute of Global Health (ISGlobal), Barcelona, Spain.

Tim Nawrot (T)

Centre for Environmental Sciences, Hasselt University, Diepenbeek, Belgium.

Nivonirina Robinot (N)

Nutrition and Metabolism Branch, International Agency for Research on Cancer, Lyon, France.

Theano Roumeliotaki (T)

Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece.

Franco Sassi (F)

Centre for Health Economics & Policy Innovation, Department of Economics & Public Policy, Imperial College Business School, South Kensington Campus, London, UK.

Augustin Scalbert (A)

Nutrition and Metabolism Branch, International Agency for Research on Cancer, Lyon, France.

Martine Vrijheid (M)

Barcelona Institute of Global Health (ISGlobal), Barcelona, Spain.
Universitat Pompeu Fabra (UPF), Barcelona, Spain.
CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.

Paolo Vineis (P)

Μedical Research Council-Health Protection Agency Centre for Environment and Health, Imperial College London, London, UK.

Lorenzo Richiardi (L)

Cancer Epidemiology Unit, Department of Medical Sciences, University of Turin and CPO-Piemonte, Torino, Italy.

Daniela Zugna (D)

Cancer Epidemiology Unit, Department of Medical Sciences, University of Turin and CPO-Piemonte, Torino, Italy.

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