PDG, KMG and YSC report receiving reimbursement for speaking at conferences sponsored by companies selling nutritional products. PDG, KMG and YSC report being part of an academic consortium that has received research funding from Abbott Nutrition, Nestle and Danone. No other disclosures were reported. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.
Conceived and designed the experiments: KK PDG KMG SMS YSC. Performed the experiments: NP. Analyzed the data: SLL SES NL FY KHT AB GSHY FMR MFFC. Wrote the paper: SLL MFFC JKYC.
‡ JKYC and MFFC are Joint Senior Authors.
¶ Membership of the GUSTO study group is provided in the Acknowledgments.
Epidemiological studies relating maternal 25-hydroxyvitamin D (25OHD) with gestational diabetes mellitus (GDM) and mode of delivery have shown controversial results. We examined if maternal 25OHD status was associated with plasma glucose concentrations, risks of GDM and caesarean section in the Growing Up in Singapore Towards healthy Outcomes (GUSTO) study.
Plasma 25OHD concentrations, fasting glucose (FG) and 2-hour postprandial glucose (2HPPG) concentrations were measured in 940 women from a Singapore mother-offspring cohort study at 26–28 weeks’ gestation. 25OHD inadequacy and adequacy were defined based on concentrations of 25OHD ≤75nmol/l and >75nmol/l respectively. Mode of delivery was obtained from hospital records. Multiple linear regression was performed to examine the association between 25OHD status and glucose concentrations, while multiple logistic regression was performed to examine the association of 25OHD status with risks of GDM and caesarean section.
In total, 388 (41.3%) women had 25OHD inadequacy. Of these, 131 (33.8%), 155 (39.9%) and 102 (26.3%) were Chinese, Malay and Indian respectively. After adjustment for confounders, maternal 25OHD inadequacy was associated with higher FG concentrations (β = 0.08mmol/l, 95% Confidence Interval (CI) = 0.01, 0.14), but not 2HPPG concentrations and risk of GDM. A trend between 25OHD inadequacy and higher likelihood of emergency caesarean section (Odds Ratio (OR) = 1.39, 95% CI = 0.95, 2.05) was observed. On stratification by ethnicity, the association with higher FG concentrations was significant in Malay women (β = 0.19mmol/l, 95% CI = 0.04, 0.33), while risk of emergency caesarean section was greater in Chinese (OR = 1.90, 95% CI = 1.06, 3.43) and Indian women (OR = 2.41, 95% CI = 1.01, 5.73).
25OHD inadequacy is prevalent in pregnant Singaporean women, particularly among the Malay and Indian women. This is associated with higher FG concentrations in Malay women, and increased risk of emergency caesarean section in Chinese and Indian women.
Vitamin D inadequacy, which is defined as serum 25-hydroxyvitamin D (25OHD) <75nmol/l in some studies [
25OHD involves in glucose homeostasis via different mechanisms. In its active form, it improves insulin sensitivity of the target cells (liver, skeletal muscle and adipose tissue) [
It has been shown that both skeletal and uterine smooth muscle contain vitamin D receptors [
Serum 25OHD levels vary according to geographical location and sunlight exposure [
The Singapore Growing Up in Singapore Towards healthy Outcomes (GUSTO) study, consisting of mothers from three ethnic groups, namely the Chinese, Malays and Indians, provides a unique opportunity to evaluate pregnancy outcomes associated with 25OHD status across ethnic groups with the absence of seasonal variation in sunlight exposure. This study aimed to examine the association of maternal 25OHD status in the second trimester of pregnancy with plasma glucose concentrations, risks of GDM and caesarean section. We hypothesized that 25OHD inadequacy was associated with higher fasting glucose (FG) and 2-hour postprandial glucose (2HPPG) concentrations, increased risks of GDM and emergency caesarean section due to prolonged labour and foetal distress.
Women were drawn from the GUSTO mother-offspring cohort study, which involved detailed assessment of pregnant women and characteristics of their offspring from birth onwards [
Pregnant women attending antenatal care (<14 weeks’ gestation) from June 2009 to September 2010 in KK Women’s and Children’s Hospital (KKH) and National University Hospital (NUH), which house the major public maternity units in Singapore, were recruited into the GUSTO study. The inclusion criteria included age range between 18 and 50 years, intention to reside in Singapore for the next five years, intention to deliver in KKH and NUH, and willingness to donate cord, cord blood and placenta. Only Chinese, Malay and Indian women whose parents and whose husband’s parents were of same ethnicity were included in the study. Women receiving chemotherapy, psychotropic drugs or with type 1 diabetes mellitus were excluded. Informed written consent was obtained from all women.
Women recruited in their first trimester returned to the hospitals at 26–28 weeks’ gestation for a follow-up visit. Detailed interviews were conducted in the clinics at recruitment and at 26–28 weeks’ gestation. Data on socioeconomic status, educational attainment, personal health, dietary supplement intake, smoking status and physical activity were collected. Smoking exposure was defined as current smoking or exposed to second hand smoke on a daily basis. After delivery, data on mode of delivery and complications were retrieved from the hospital case notes by trained health personnel.
Three types of physical activity were assessed, including light-moderate, moderate and vigorous intensity activities. Total level of physical activity was computed from the summation of the duration (in minutes) and frequency (days) of these three types of activity. Physical activity was expressed in metabolic equivalents (MET-minutes/week) and classified as not highly active (<3000 MET-minutes/week) and highly active (≥3000 MET minutes/week) levels [
Maternal height was measured with a stadiometer (Seca 206, Hamburg, Germany). Maternal weight was based on body weight measured at first antenatal clinic visit during the first trimester of pregnancy. Body mass index (BMI) was computed from the formula: weight (kg)/ height (m2). Because obesity is a risk factor of low 25OHD [
An overnight fasting blood samples were drawn at 26–28 weeks’ gestation for glucose and 25OHD analyses. At the same visit, women underwent 75g Oral Glucose Tolerance Test (OGTT) for GDM diagnosis using World Health Organization criteria (FG or 2HPPG concentrations ≥7.0 or ≥7.8mmol/l respectively) [
Plasma 25OHD was analysed as 25-hydroxyvitamin D2 (25OHD2) and 25-hydroxyvitamin D3 (25OHD3) by isotope-dilution liquid chromatography–tandem mass spectrometry (ID-LC-MS/MS) [
Categorical data were presented as frequencies and percentages, while continuous data were presented as means and standard deviations. Comparisons between maternal characteristics and 25OHD status were performed using Pearson’s Chi-square test for categorical variables and independent t-test for continuous variables. Multiple logistic regression analysis was used to assess the association of 25OHD status with risks of GDM and caesarean sections (total caesarean section, emergency caesarean section and related indications, and elective caesarean section). Multiple linear regression analysis was used to assess the association of 25OHD status with FG and 2HPPG concentrations.
Both logistic and linear regression models were adjusted for confounding variables, which included maternal age, parity, ethnicity, education, body mass index, smoking exposure, physical activity during pregnancy, and pre-existing diabetes and / or hypertension. These confounders were selected based on literature review [
Of 1152 pregnant women who were recruited in the study at <14 weeks’ gestation, 1087 (94.4%) of them remained until the delivery stage (
Characteristics | Total (n = 940) | 25OHD inadequacy (n = 388) | 25OHD adequacy (n = 552) | p |
---|---|---|---|---|
Plasma 25OHD, nmol/l | 81.03 (27.18) | 55.43 (13.81) | 99.02 (18.40) | <0.001 |
Age, years | 30.53 (5.11) | 29.54 (5.12) | 31.24 (4.99) | <0.001 |
Ethnicity, n (%) | ||||
Chinese | 519 (55.2) | 131 (25.2) | 388 (74.8) | <0.001 |
Malay | 247 (26.3) | 155 (62.8) | 92 (37.2) | |
India | 174 (18.5) | 102 (58.6) | 72 (41.4) | |
Parity, n (%) | ||||
Nulliparous | 402 (42.8) | 162 (40.3) | 240 (59.7) | 0.599 |
Multiparous | 538 (57.2) | 226 (42.0) | 312 (58.0) | |
Body mass index (kg/m-2) | ||||
Underweight, n (%) | 77 (8.2) | 30 (39.0) | 47 (61.0) | 0.008 |
Normal weight, n (%) | 571 (61.1) | 222 (38.9) | 349 (61.1) | |
Overweight, n (%) | 186 (19.9) | 77 (41.4) | 109 (58.6) | |
Obese, n (%) | 100 (10.7) | 57 (57.0) | 43 (43.0) | |
Education, n (%) | ||||
None/ Primary/ Secondary | 284 (30.6) | 117 (41.2) | 167 (58.8) | 0.007 |
Post-secondary | 326 (35.2) | 154 (47.2) | 172 (52.8) | |
University and others | 317 (34.2) | 111 (35.0) | 206 (65.0) | |
Smoking exposure, n (%) | 344 (36.8) | 163 (42.1) | 181 (33.0) | 0.004 |
Intake of supplement containing vitamin D and Calcium, n (%) | 635 (74.6) | 228 (68.1) | 407 (78.9) | <0.001 |
Physical activity, n (%) | ||||
Not highly active | 746 (80.6) | 308 (41.3) | 438 (58.7) | 0.881 |
Highly active | 179 (19.4) | 75 (41.9) | 104 (58.1) | |
Pre-existing diabetes and/ or hypertension, n (%) | 19 (2.0) | 8 (2.1) | 11 (2.0) | 0.941 |
Neonatal sex, n (%) | ||||
Boys | 489 (52.0) | 186 (38.0) | 303 (62.0) | 0.036 |
Girls | 451 (48.0) | 202 (44.8) | 249 (55.2) | |
FG concentrations, mmol/l | 4.35 (0.47) | 4.39 (0.54) | 4.31 (0.42) | 0.020 |
2HPPG concentrations, mmol/l | 6.49 (1.44) | 6.43 (1.51) | 6.53 (1.40) | 0.303 |
GDM, n (%) | 155 (17.7) | 59 (16.8) | 96 (18.3) | 0.570 |
Caesarean section, |
279 (29.7) | 122 (31.4) | 157 (28.4) | 0.321 |
Emergency caesarean section, n (%) | 183 (21.7) | 86 (24.4) | 97 (19.7) | 0.101 |
Prolonged labour, n (%) | 68 (8.1) | 30 (8.5) | 38 (7.7) | 0.674 |
Foetal distress, n (%) | 67 (7.9) | 32 (9.1) | 35 (7.1) | 0.295 |
Elective caesarean section, n (%) | 96 (10.2) | 36 (11.9) | 60 (13.2) | 0.608 |
a Total sample size is not always n = 940 due to the missing values. Data are presented as mean (standard deviation) or number (percentage). 25OHD inadequacy = 25OHD ≤75nmol/l; 25OHD adequacy = 25OHD>75nmol/l.
b p values are determined by independent t-test or Pearson chi-square test.
c Included both emergency and elective caesarean sections.
25OHD = 25-hydroxyvitamin D; FG = fasting glucose; 2HPPG = 2-hour postprandial glucose; GDM = gestational diabetes mellitus
Variables | Chinese (n = 519) | Malay (n = 247) | Indian (n = 174) | ||||||
---|---|---|---|---|---|---|---|---|---|
25OHD inadequacy (n = 131) | 25OHD adequacy (n = 388) | p |
25OHD inadequacy (n = 155) | 25OHD adequacy (n = 92) | p |
25OHD inadequacy (n = 102) | 25OHD adequacy (n = 72) | p |
|
FG concentrations, mmol/l | 4.33 (0.51) | 4.31 (0.42) | 0.741 | 4.39 (0.60) | 4.25 (0.38) | 4.48 (0.49) | 4.39 (0.46) | 0.266 | |
2HPPG concentrations, mmol/l | 6.67 (1.43) | 6.60 (1.40) | 0.622 | 6.20 (1.49) | 6.20 (1.31) | 0.995 | 6.47 (1.62) | 6.59 (1.46) | 0.629 |
GDM | 24 (20.0) | 75 (20.3) | 0.949 | 14 (9.8) | 8 (9.0) | 0.839 | 21 (23.6) | 13 (19.4) | 0.530 |
Caesarean section |
42 (32.1) | 104 (26.8) | 0.247 | 40 (25.8) | 30 (32.6) | 0.251 | 40 (39.2) | 23 (31.9) | 0.326 |
Emergency caesarean section | 27 (23.3) | 65 (18.6) | 0.276 | 27 (19.0) | 21 (25.3) | 0.267 | 32 (34.0) | 11 (18.3) | |
Prolonged labour | 10 (8.6) | 27 (7.7) | 0.760 | 13 (9.2) | 8 (9.6) | 0.904 | 7 (7.4) | 3 (5.0) | 0.548 |
Foetal distress | 8 (6.9) | 21 (6.0) | 0.734 | 14 (9.9) | 9 (10.8) | 0.814 | 10 (10.6) | 5 (8.3) | 0.638 |
Elective caesarean section | 15 (14.4) | 39 (12.1) | 0.531 | 13 (10.2) | 9 (12.7) | 0.587 | 8 (11.4) | 12 (19.7) | 0.191 |
Data are presented as mean (standard deviation) or number (percentage). 25OHD inadequacy = 25OHD ≤75nmol/l; 25OHD adequacy = 25OHD>75nmol/l. The values in bold indicate p<0.05.
a p values are determined by chi-square test or independent t-test.
b Included both emergency and elective caesarean sections.
25OHD = 25-hydroxyvitamin D; FG = fasting glucose; 2HPPG = 2-hour postprandial glucose; GDM = gestational diabetes mellitus.
Crude | Adjusted | |||||
---|---|---|---|---|---|---|
Maternal outcomes | 25OHD adequacy | 25OHD inadequacy | 25OHD adequacy | 25OHD inadequacy | ||
OR (95% CI) |
p | OR (95% CI) |
p | |||
FG concentrations, mmol/l | reference | 0.08 (0.02, 0.14) |
Reference | 0.08 (0.01, 0.14) |
||
2HPPG concentrations, mmol/l | reference | -0.10 (-0.30, 0.09) |
0.303 | Reference | 0.05 (-0.15, 0.25) |
0.631 |
GDM | reference | 0.90 (0.63, 1.29) | 0.571 | Reference | 1.02 (0.68, 1.53) | 0.938 |
Caesarean section |
reference | 1.15 (0.87, 1.53) | 0.322 | Reference | 1.15 (0.83, 1.58) | 0.406 |
Emergency caesarean section | reference | 1.32 (0.95, 1.83) | 0.102 | Reference | 1.39 (0.95, 2.05) | 0.092 |
Prolonged labour | reference | 1.11 (0.68, 1.83) | 0.674 | Reference | 1.24 (0.68, 2.27) | 0.480 |
Foetal distress | reference | 1.31 (0.79, 2.15) | 0.296 | Reference | 1.08 (0.61, 1.91) | 0.788 |
Elective caesarean section | reference | 0.89 (0.57, 1.39) | 0.608 | Reference | 0.76 (0.47, 1.24) | 0.277 |
Adjusted for maternal age, parity, ethnicity, education, body mass index, smoking exposure, physical activity, pre-existing diabetes and/ or hypertension, neonatal sex. 25OHD inadequacy = 25OHD ≤75nmol/l; 25OHD adequacy = 25OHD>75nmol/l. The values in bold indicate p<0.05.
a Data are presented as Odds Ratio (95% Confidence Interval), unless otherwise indicated.
b Data are presented as β regression coefficient (95% Confidence Interval)
c Included both emergency and elective caesarean sections.
25OHD = 25-hydroxyvitamin D; FG = fasting glucose; 2HPPG = 2-hour postprandial glucose; GDM = gestational diabetes mellitus
When analyses were stratified by ethnicity (
Chinese | Malay | Indian | |||||||
---|---|---|---|---|---|---|---|---|---|
Pregnancy outcomes | 25OHD adequacy | 25OHD inadequacy | 25OHD adequacy | 25OHD inadequacy | 25OHD adequacy | 25OHD inadequacy | |||
OR |
P | OR |
p | OR |
p | ||||
FG concentrations, mmol/l | reference | 0.03 (-0.06, 0.12) |
0.507 | Reference | 0.19 (0.04, 0.33) |
reference | 0.09 (-0.07, 0.24) |
0.268 | |
2HPPG concentrations, mmol/l | reference | 0.10 (-0.21, 0.36) |
0.616 | Reference | 0.12 (-0.24, 0.49) |
0.509 | reference | 0.08 (-0.42, 0.59) |
0.747 |
GDM | reference | 0.92 (0.54, 1.59) | 0.771 | Reference | 1.36 (0.50, 3.72) | 0.546 | reference | 01.34 (0.55, 3.24) | 0.520 |
Caesarean section |
reference | 1.46 (0.91, 2.35) | 0.117 | Reference | 0.67 (0.37, 1.23) | 0.194 | reference | 1.42 (0.70, 2.89) | 0.337 |
Emergency caesarean section | reference | 1.90 (1.06, 3.43) | Reference | 0.56 (0.28, 1.15) | 0.115 | reference | 2.41 (1.01, 5.73) | ||
Prolonged labour | reference | 1.91 (0.80, 4.58) | 0.146 | Reference | 0.76 (0.27, 2.14) | 0.599 | reference | 1.50 (0.32, 7.04) | 0.608 |
Foetal distress | reference | 1.41 (0.55, 3.59) | 0.477 | Reference | 0.73 (0.28, 1.94) | 0.533 | reference | 1.33 (0.33, 5.29) | 0.690 |
Elective caesarean section | reference | 1.02 (0.52, 2.01) | 0.948 | Reference | 0.98 (0.37, 2.61) | 0.967 | reference | 0.35 (0.12, 1.01) | 0.052 |
Adjusted for maternal age, parity, education, body mass index, smoking exposure, physical activity, pre-existing diabetes and/ or hypertension, neonatal sex. 25OHD inadequacy = 25OHD ≤75nmol/l; 25OHD adequacy = 25OHD>75nmol/l. The values in bold indicate p<0.05.
a Data are presented as Odds Ratio (95% Confidence Interval), unless otherwise indicated.
b Data are presented as β regression coefficient (95% Confidence Interval)
c Included both emergency and elective caesarean sections.25OHD = 25-hydroxyvitamin D; FG = fasting glucose; 2HPPG = 2-hour postprandial glucose; GDM = gestational diabetes mellitus.
In this multi-ethnic cohort, 41% of pregnant women were found to have inadequate plasma levels of 25OHD in the second trimester, with substantially higher rates found in Malay and Indian women compared to Chinese women. Overall, maternal 25OHD inadequacy was significantly associated with higher FG concentrations, and a trend towards higher likelihood of emergency caesarean delivery. By ethnicity, the association between inadequate 25OHD status and higher FG concentrations was found to be significant only in Malay women, while the odds of having emergency caesarean section were approximately two times greater in Chinese and Indian women with 25OHD inadequacy. We found no association of maternal 25OHD status with 2HPPG concentrations, risks of GDM and non-emergency caesarean sections in the overall cohort as well as within any ethnic group.
Our observation mostly supports the findings of previous studies regarding the association between 25OHD and glucose metabolism in obstetric populations. In line with previous studies [
While two previous studies from Australia involving approximately 300 women have shown an inverse association between 25OHD and FG independent of ethnicity [
The association between serum 25OHD and GDM in the literature is conflicting [
In a cross-sectional study of 253 women, 25OHD<37.5nmol/l measured at birth was associated with a fourfold increased risk of caesarean section [
The strengths of this study include its prospective study design [
In conclusion, while prevalence of 25OHD deficiency is low, 25OHD inadequacy is highly prevalent during pregnancy in Singaporean women, particularly among Malay and Indian women. This is associated with higher FG concentrations in Malay women and an increased risk of emergency caesarean section in Chinese and Indian women. This may suggest varying threshold effects of 25OHD sensitivity on pregnancy outcomes among ethnic groups. Further investigations on biological components, social, nutritional practices and cultural differences are required to explain the mechanism of ethnicity disparity in 25OHD effects. Nevertheless, the present findings are important to provide evidence for clinical recommendations regarding potential screening of 25OHD inadequacy during prenatal care and the need for vitamin D supplementation in at risk groups.
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The GUSTO study group includes:
Allan Sheppard, Developmental Epigenetics Group, The Liggins Institute, University of Auckland, New Zealand
Amutha Chinnadurai, Department of Neonatology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
Anne Eng Neo Goh, Allergy Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore
Anne Rifkin-Graboi, Singapore Institute for Clinical Sciences, the Agency for Science, Technology and Research, Singapore
Anqi Qiu, Department of Biomedical Engineering, National University of Singapore, Singapore; Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore; Clinical Imaging Research Centre, National University of Singapore, Singapore
Arijit Biswas, Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
Bee Wah Lee, Department of Paediatrics, University Children’s Medical Institute, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
Birit F.P. Broekman, Singapore Institute for Clinical Sciences, the Agency for Science, Technology and Research, Singapore; Department of Psychological Medicine, Yong Loo Lin, School of Medicine, National University of Singapore and National University Health System, Singapore
Boon Long Quah, Singapore National Eye Centre, Singapore; Department of Ophthalmology, KK Women’s and Children’s Hospital, Singapore
Borys Shuter, Department of Diagnostic Radiology, National University of Singapore, Singapore
Chai Kiat Chng, Dental Service, KK Women's and Children's Hospital, Singapore
Cheryl Ngo, Department of Opthalmology, National University Hospital, Singapore
Stephen Chin-Ying Hsu, Department of Preventive Dentistry, Faculty of Dentistry, National University of Singapore, Singapore
Choon Looi Bong, Paediatric Anaesthesia, KK Women's and Children's Hospital, Singapore
Christiani Jeyakumar Henry, Clinical Nutrition Research Centre, Singapore Institute for Clinical Sciences, Singapore
Cornelia Yin Ing Chee, Department of Psychological Medicine, Yong Loo Lin School of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
Doris Fok, Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
Fabian Yap, Paediatric Endocrinology, KK Women’s and Children’s Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore
George Seow Heong Yeo, Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore
Hazel Inskip, MRC Life-course Epidemiology Unit, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
Helen Chen, Mental Wellness Service, Department of Psychological Medicine, KK Women’s and Children’s Hospital, Singapore
Hugo P S van Bever, Department of Paediatrics, Children’s Medical Institute, National University Hospital, National University Health System, Singapore
Iliana Magiati, Department of Psychology, National University of Singapore, Singapore
Inez Bik Yun Wong, Paediatric Ophthalmology and Strabismus Service, Department of Ophthalmology, National University Hospital, Singapore
Ivy Yee-Man Lau, School of Social Sciences, Singapore Management University, Singapore
Jeevesh Kapur, Department of Diagnostic Imaging, National University Hospital, Singapore
Jenny L. Richmond, School of Psychology, University of New South Wales, Sydney, NSW, Australia
Jerry Kok Yen Chan, KK Research Centre, KK Women’s and Children’s Hospital, Singapore; Department of Reproductive Medicine, KK Women’s and Children’s Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore
Joanna D. Holbrook, Growth, Development and Metabolism Programme, Singapore Institute for Clinical Sciences, Agency for Science Technology and Research, Singapore
Joshua J. Gooley, Program in Neuroscience and Behavioral Disorders, Duke-NUS Graduate Medical School, Singapore; Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital, Boston USA; Division of Sleep Medicine, Harvard Medical School, Boston, USA
Keith M. Godfrey, MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, United Kingdom; NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
Kenneth Kwek, Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore
Kok Hian Tan, Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore
Krishnamoorthy Niduvaje, Department of Neonatology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
Leher Singh, Department of Psychology, National University of Singapore, Singapore
Lin Lin Su, Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, SingaporeLourdes Mary Daniel, Department of Neonatology, KK Women’s and Children’s Hospital, Singapore
Lynette Pei-Chi Shek, Department of Paediatrics, University Children’s Medical Institute, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
Marielle V. Fortier, Department of Diagnostic Imaging, KK Women’s and Children’s Hospital, Singapore
Mark Hanson, Institute of Developmental Sciences, Faculty of Medicine, University of Southampton; NIHR Nutrition Biomedical Research Centre, University Hospital Southampton, United Kingdom
Mary Foong-Fong Chong, Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore; Clinical Nutrition Research Centre, Singapore Institute for Clinical Sciences, Agency for Science Technology and Research, Singapore; Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
Mary Rauff, Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Mei Chien Chua, Department of Neonatology, KK Women’s and Children’s Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore
Michael Meaney, Singapore Institute for Clinical Sciences, Agency for Science Technology and Research, Singapore; Departments of Psychiatry and Neurology & Neurosurgery, McGill University, Montreal, Canada
Mya Thway Tint, Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, National University of Singapore and National University Health System, Singapore
Ngee Lek, Paediatric Endocrinology, KK Women’s and Children’s Hospital, Singapore; Duke-NUS Graduate Medical School, Singapore
Oon Hoe Teoh, Respiratory Medicine Service, Department of Paediatric Medicine, KK Women’s and Children’s Hospital, Singapore
Peng Cheang Wong, Department of Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
Peter D. Gluckman, Singapore Institute for Clinical Sciences, Agency for Science Technology and Research, Singapore; Liggins Institute, University of Auckland, Auckland, New Zealand
Pratibha Agarwal, Department of Neonatology, KK Women’s and Children’s Hospital, Singapore
Rob M. van Dam, Saw Swee Hock School of Public Health and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
Salome A. Rebello, Life Sciences Institute, Centre for Life Sciences, National University of Singapore, Singapore
Seang-Mei Saw, Saw Swee Hock School of Public Health, National University of Singapore, Singapore and Myopia Unit, Singapore Eye Research Institute, Singapore
Shang Chee Chong, Division of Paediatric Neurology, Developmental and Behavioural Paediatrics, University Children’s Medical Institute, National University of Singapore and National University Health System, Singapore
Shirong Cai, Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
Shu-E Soh, Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore
Sok Bee Lim, Department of Child Development, KK Women’s & Children’s Hospital, Singapore
Victor Samuel Rajadurai, Department of Neonatology, KK Women's & Children's Hospital, Singapore
Walter Stunkel, Singapore Institute for Clinical Sciences, Agency for Science Technology and Research, Singapore
Wee Meng Han, Department of Nutrition and Dietetics, KK Women’s and Children’s Hospital, Singapore
Wei Wei Pang, Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
Yam Thiam Daniel Goh, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
Yap-Seng Chong, Singapore Institute for Clinical Sciences, Agency for Science Technology and Research, Singapore; Obstetrics & Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
Yin Bun Cheung, Center for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore; Department for International Health, University of Tampere, Finland
Yiong Huak Chan, Medicine Dean's Office, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Yung Seng Lee, Growth, Development and Metabolism Programme, Singapore Institute for Clinical Sciences, Agency for Science Technology and Research, Singapore; Paediatric Endocrinology and Diabetes, University Children's Medical Institute, National University Health System, Singapore; Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Lead author GUSTO group: A/Prof Yap-Seng Chong, email: