Strengths and limitations
The main strength of the study is the substantial sample size of women from the three largest ethnicities in Singapore (Chinese, Malay and Indian), and the results are likely generalizable to the Asian population. In addition, the study used gestational-age-adjusted BMI, allowing a more accurate comparison of interpregnancy BMI change. However, since BMI is an imperfect measurement of metabolic health,34 more needs to be done to investigate how other markers of metabolic health, such as insulin resistance, lipid profile and body composition, are associated with adverse perinatal outcomes beyond a change in BMI. The GDM screening policy underwent a transition during the study period, from a risk-based 2-point OGTT between 2015-2017 to a universal 3-point OGTT from 2018-2020, thus, the incidence of GDM may be underestimated in the earlier years.39, 40 We did not account for the socioeconomic status and lifestyle habits of the women in the analysis due to the lack of data from medical records. Finally, long-term outcomes of these women and their offspring were not available to provide insights on their long-term health.