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.