The Growing Up in Singapore Towards healthy Outcomes (GUSTO) study has been previously described in detail23. Briefly, pregnant women were recruited in their first trimester at two major public hospitals in Singapore with obstetric services (KK Women’s and Children’s Hospital and the National University Hospital) between June 2009 and September 2010. Eligible women were Singapore citizens or permanent residents who were of Chinese, Malay, or Indian ethnicity with homogeneous parental ethnic backgrounds, and did not receive chemotherapy or psychotropic drugs and did not have diabetes mellitus. Of 3751 women approached, 2034 were eligible, 1247 were recruited and 1170 had singleton deliveries (Supplemental Fig. 1). The reasons of ineligibility have been previously described in detail23. Informed written consent was obtained from the women, and the study was approved by the National Healthcare Group Domain Specific Review Board and SingHealth Centralized Institutional Review Board. All methods were performed in accordance with the relevant guidelines and regulations, and ethical approval was granted by the National Healthcare Group Domain Specific Review Board and SingHealth Centralized Institutional Review Board.
Socio-demographic data (age, self-reported ethnicity, educational attainment, income level and parity) were obtained at recruitment. Pregnant women underwent a 2-hour, 75-gram oral glucose tolerance test after an overnight fast at 26–28 weeks of gestation, as detailed previously24; those diagnosed with gestational diabetes based on World Health Organization’s (WHO) criteria [FPG ≥ 7.0 mmol/L or 2-hour glucose ≥7.8 mmol/L] were placed on a diet or treated with insulin. Gestational age (GA) was assessed by trained ultrasonographers at the first dating scan after recruitment and was reported in completed weeks.
Maternal pre-pregnancy weight was self-reported at study enrolment. Measurements of weight and height for mothers during pregnancy were obtained using SECA 803 Weighing Scale and SECA 213 Stadiometer (SECA Corp, Hamburg, Germany). These measurements were used to calculate body mass index (BMI) in kg/m2. Gestational weight gain (GWG) was calculated as the difference between last measured weight before delivery (between 35–37 weeks of gestation) and pre-pregnancy weight, and was corrected for gestational duration using maternal weight-gain-for-gestational age z-score charts by Hutcheon et al.25. Maternal blood pressure (BP) at 26–28 weeks of gestation was taken by trained research coordinators with an oscillometric device (MC3100, HealthSTATS International Pte Ltd, Singapore).
Mothers were asked about infant milk feeding using interviewer-administered questionnaires at home visits when the infants were 3, 6, 9, and 12 months of age. Feeding practices were classified into exclusive, predominant, and partial breastfeeding at each of those ages. Both direct breastfeeding and expressed breast milk intakes were classified as breastfeeding. Infants were defined as having low, intermediate or high breastfeeding, as detailed previously26.
Child anthropometric measurements
Measurements of child weight and length/height were obtained at birth, 3, 6, 9, 12, 15 and 18 months and 2 years and 5 years of age, as detailed previously27, 28. At 5 years, we measured waist circumference, four skinfold thicknesses (triceps, biceps, subscapular and suprailiac), fat and lean mass [in a subset of children (n = 274) whose parents provided written consent] based on quantitative magnetic resonance imaging, as detailed previously29. These measurements were used to calculate BMI, sum of skinfolds (SSF), waist-to-height ratio (WHtR), fat mass index (FMI) and lean mass index (LMI) (calculated as fat or lean mass divided by square of height). Age- and sex-specific BMI z-scores (BMIz) were calculated using WHO refs 30, 31. Child obesity at 5 years was defined as age- and sex-specific BMIz two standard deviations higher than the median of the WHO ref. 31.
Based on standardized protocols32, child BP at 5 years was measured by trained research coordinators using a Dinamap CARESCAPE V100 (GE Healthcare, Milwaukee, WI), with the arm resting at the chest level. An average of two blood pressure readings were calculated if the difference between readings was <10 mmHg; otherwise, a third reading was taken and the average of the three readings used instead. Child prehypertension was defined as systolic (SBP) or diastolic (DBP) BP above the 90th percentile for the child’s sex, age and height. As there is currently no reference for blood pressure percentiles in the Singapore population, we utilized reference values published by the American Academy of Pediatrics33.
Stage 1: Modelling BMIz trajectories in the first 2 years using LCGMM
We analyzed child BMIz trajectories in the first 2 years of life using LCGMM10, 11. LCGMM is a longitudinal technique based on structural equation modelling that incorporates both continuous and categorical latent (unobserved) variables. The technique assumes that individuals in the sample need not come from a single underlying population, but rather from multiple, latent subgroups. Each identified subgroup has its own specific parameters (e.g., intercept, slope, quadratic), which are unobserved. Furthermore, LCGMM accounts for within-class variation in all growth parameters, implying within-class heterogeneity in addition to the between-class heterogeneity among the identified subgroups.
Quadratic-shaped trajectories were fitted, allowing for curved developmental patterns, with an increasing number of latent trajectories, assuming a constant variance–covariance structure (correlated random intercept, linear, quadratic function). The proportions of missing BMIz data at each time point and across all time points in the first 2 years are shown in Supplemental Table 1; 87.5% of children had at least 4 measurements of BMI in the first 2 years. We used the maximum likelihood robust estimator to account for missing data by full information maximum likelihood. This process approximates missing data by estimating a likelihood function for each individual based on variables that are present, such that all the available data points are used34. We identified the optimal number of latent trajectories based on two model-fit indices: the Bayesian Information Criterion (BIC) and the Bootstrap Likelihood Ratio Test (BLRT). A lower BIC value indicates a better model fit, while the BLRT provides a p-value indicating whether a model with one fewer trajectory groups (k-1 model) should be rejected in favour of a model with k trajectories. Posterior probabilities of belonging to each trajectory were also examined, with subjects assigned to the trajectory for which they had the highest posterior probability. We required each trajectory to contain a minimum of 5% of subjects, so that it would be large enough to be clinically important. Distinct trajectories were coded as a categorical variable (with k number of categories) and were named based on their visual appearance. As the trajectories were similar in nature in both girls and boys (as found in other studies13, 14), all analyses were performed on the total sample. In addition, when corrected postnatal age for infants born preterm35 was used in deriving the trajectories, the patterns were exactly the same as those derived using uncorrected postnatal age. In light of this, all analyses were performed using uncorrected postnatal age. To illustrate the robustness of the extracted trajectories, we repeated the analyses restricted to children with no missing BMIz data in the first 2 years (n = 536). All LCGMM analyses were conducted using Mplus version 7.4 (Muthén and Muthén, Los Angeles, CA).
Stage 2: Predictors and cardio-metabolic consequences of BMIz trajectories
Associations between maternal (age, income level, pre-pregnancy BMI (ppBMI), height, GWG, GDM status, parity and GA at delivery) and infant (ethnicity and breastfeeding) factors and BMIz trajectories were first examined using ordinal logistic regression. However, the proportional odds assumption was violated (Brant test p < 0.05) for many of the predictors (ppBMI, height, GWG, income level, ethnicity and GA at delivery), rendering the model unsuitable for analysis and interpretation. We therefore used multinomial logistic regression, with the most commonly occurring trajectory chosen as the reference category. As self-reported pre-pregnancy weight may have limited validity, we also carried out sensitivity analyses by replacing ppBMI with maternal BMI at booking (mean 8.7 ± 2.8 weeks of gestation).
We studied the association between BMIz trajectories and cardio-metabolic measures at 5 years (i.e., WHtR, SSF, FMI, LMI, SBP and DBP) using multivariable linear regression. As the distributions of child WHtR, SSF, FMI and LMI were skewed, the data were log-transformed and standardized to z-scores with a mean 0 and SD of 1. The log-transformation reduced the skewness and the problem of non-normality. Poisson regression models with robust variance were used to calculate the relative risk of obesity or prehypertension at 5 years for each distinct BMIz trajectory.
For comparison, we also estimated the relative risk of obesity or prehypertension at 5 years for the (static) BMIz measurement at 2 years, categorized into four levels: <5th, 5th–<85th, 85th–<95th or ≥95th percentiles and compared those adjusted relative risk estimates to those associated with BMIz trajectories. To assess the variance of continuous cardio-metabolic outcomes explained by trajectory vs static BMIz groupings beyond baseline covariates, a basic model was first fitted by including predictors of cardio-metabolic outcomes (maternal income level, ppBMI, height, GWG, parity, GA at delivery, breastfeeding, child ethnicity, and sex) as independent variables in a linear regression analysis. Subsequently, the trajectory or static BMIz groupings were added separately to those baseline models; the increment in variance explained beyond that of baseline covariates was assessed using the adjusted R2 values. The area under the receiver operating characteristics (ROC) curve was also used to compare the predictive value of trajectory vs static BMIz groupings for obesity and prehypertension at 5 years.
All models were adjusted for maternal income level, ppBMI, GWG, parity, GA at delivery, breastfeeding, child ethnicity, and sex to reduce confounding, and exact age at measurement to improve precision. Recent studies have found a relationship between maternal height and offspring adiposity in childhood36; therefore, we also considered maternal height as a potential confounding variable in the analysis. Multiple imputation was used to account for missing covariates (maternal income level, n = 77; ppBMI, n = 105; height, n = 27; GWG, n = 33; breastfeeding, n = 142) with 20 imputations based on the Markov-chain Monte Carlo technique, using MI IMPUTE to impute the missing values and MI ESTIMATE to analyze the imputed datasets. These analyses were performed using Stata 13 software (StataCorp LP, TX).
Data are available from the National University of Singapore LORIS Database for researchers who meet the criteria for access to confidential data.
To investigate the relationship between the pretreatment body mass index (BMI) and the clinical outcomes in patients with locoregionally advanced nasopharyngeal carcinoma treated with combination of chemotherapy and radiotherapy.
From August 2002 to April 2005, 400 patients with stage III or stage IVa nasopharyngeal carcinoma were recruited for a randomised clinical trial of induction chemotherapy combined with radiotherapy or concurrent chemoradiotherapy. The patients were divided into four groups of underweight (BMI < 18.5 kg/m2), normal weight (BMI 18.5–22.9 kg/m2), overweight (BMI 23.0–27.4 kg/m2) or obese (BMI ⩾ 27.5 kg/m2) according to the World Health Organization classifications for Asian populations. The differences in the long-term survival, of these four BMI groups were analysed.
The 5-year failure-free survival rates for the underweight, normal weight, overweight and obese groups were 44%, 61%, 68% and 73%, respectively (p = 0.014), and the 5-year overall survival rates were 51%, 68%, 80% and 72% (p = 0.001), respectively. BMI was a strongly favoured prognostic factor of overall survival and failure-free survival in a Cox regression model.
Pretreatment body mass index was a simple, reliable independent prognostic factor for patients with locoregionally advanced nasopharyngeal carcinoma treated with chemoradiotherapy.