DIABETES/METABOLISM RESEARCH AND REVIEWS RESEARCH ARTICLE

Diabetes Metab Res Rev 2006; 22: 131–138.

Published online 19 September 2005 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/dmrr.591

Do adiponectin, TNFα, leptin and CRP relate

to insulin resistance in pregnancy? Studies in
women with and without gestational diabetes,
during and after pregnancy

Kylie A. McLachlan1 * Abstract

David O’Neal2
Alicia Jenkins2
Frank P. Alford1
1 and in controls, during and after pregnancy, and related them to insulin
Department of Endocrinology,
St Vincents Hospital, Victoria,
Australia
2
Department of Medicine, St Vincent’s
Hospital, Victoria, Australia
*Correspondence to: Kylie A.
McLachlan, St Vincent Hospital,
Endocrinology & Diabetes, PO Box
2900, Fitzroy 3065, Melbourne,
Victoria, Australia.
E-mail: jane.ford@svhm.org.au
Background The role of adiponectin, tumour necrosis factor α (TNFα),
leptin and C-reactive protein in the insulin resistance of pregnancy is not
clear. We measured their levels in women with gestational diabetes (GDM)
secretion and action.
Methods Nineteen women with GDM and 19 BMI-matched healthy
pregnant women underwent intravenous glucose tolerance tests in the
third trimester of pregnancy and 4 months postpartum to determine insulin
sensitivity (SI) and insulin secretion. Adiponectin, TNFα, leptin and high
sensitivity CRP (hsCRP) were measured in fasted blood.
Results Of the circulating factors, only leptin (r = −0.41, p = 0.01)
correlated with SI in pregnancy. Leptin and hsCRP levels were elevated in
pregnancy compared to postpartum (leptin (mean ± SEM): 27.8 ± 2.4 vs
19.3 ± 2.1 ng/mL, p < 0.001; hsCRP: 5.2 ± 0.7 vs 3.2 ± 0.6 mg/L, p <
0.001). Adiponectin levels did not change from pregnancy to postpartum,
despite a marked increase in SI. All four factors correlated with SI postpartum
(adiponectin: r = 0.38, p = 0.01; TNFα: r = −0.48, p = 0.002; Leptin: r =
−0.61, p = 0.001; hsCRP: r = −0.48, p = 0.002). TNFα correlated inversely
with insulin secretion in pregnancy (r = −0.35, p = 0.03) and was
significantly higher in the GDM group (2.62 ± 0.3 vs 1.88 ± 0.3 pg/mL,
p = 0.01) in pregnancy.

Conclusion In our study, the influence of adiponectin, TNFα and hsCRP

upon SI is overwhelmed by other factors in pregnancy. While leptin and SI
correlated in pregnancy, it is unclear whether this represents cause or effect.
Finally, TNFα may exert an inhibitory effect on insulin secretion in GDM,
contributing to the associated hyperglycaemia. Copyright  2005 John Wiley
& Sons, Ltd.

Keywords gestational diabetes; adipocytokines; pregnancy; insulin resistance;

insulin secretion

Introduction
Received: 3 September 2004
Accepted: 27 June 2005 During pregnancy, insulin sensitivity (IS) declines by 50% by the third
trimester [1], which may be mediated by increases in hormones such as

Copyright  2005 John Wiley & Sons, Ltd.

132
oestrogen, progesterone, β-human chorionic gonadotro-
phin, human placental lactogen, growth hormone and
cortisol [2]. A recent study of 15 subjects suggested a role
for tumour necrosis factor α (TNFα) [3] in this pregnancy-
induced insulin resistance, and other studies have found
associations between TNFα and surrogate measures of
insulin sensitivity such as fasting C-peptide [4]. The
role of adiponectin, which enhances insulin action and
exerts opposite effects to TNFα [5], is beginning to be
explored during normal and diabetic pregnancy [6,7].
No studies to date, however, have examined adiponectin
levels in pregnancy employing the techniques that permit
the precise measurement of insulin sensitivity.
Women with gestational diabetes (GDM) demonstrate
defects in insulin secretion during pregnancy and defects
in insulin sensitivity and secretion postpartum [8,9].
Given that there are possible important roles for the
adipocytokines in the early defects of type 2 diabetes,
GDM women represent an ideal population to study
these inter-relationships further. To date, there is limited
cross-sectional information that TNFα may be elevated
in GDM pregnancy [4,10]. Other cross-sectional reports
have shown that adiponectin levels are reduced in women
with GDM [6,7,11,12]. Leptin, an adipocytokine, which
is also produced by the placenta and is involved with
weight regulation and metabolism, has been variously
reported as being elevated [13], normal [14] or reduced
[15] in GDM pregnancy. Given the uncertainties with
the current cross-sectional adipocytokine data, a role for
these cytokines in the pathophysiology of GDM has not
been clearly established.
The purpose of this study was therefore to determine if
these cytokines were (1) linked to the insulin resistance
or insulin secretion of late pregnancy, (2) altered in
GDM compared to non-diabetic pregnant women and
(3) related to persisting insulin secretion and action
defects of former GDM women postpartum. Since
adipocytokines are secreted from adipose tissue and relate
strongly to adiposity, it is important to match for adiposity
to remove it as a confounding factor, when investigating
the possible role in GDM. To this end, we employed a
frequently sampled intravenous glucose tolerance test
(FSIVGTT) to measure insulin sensitivity and insulin
secretion during late pregnancy and postpartum in a
group of women with GDM and age- and BMI (body mass
index)-matched healthy pregnant women.
Materials and methods
Subjects
Subjects were recruited from the obstetric clinics of the
Mercy Hospital for Women, Box Hill and Werribee Mercy
Hospitals. Nineteen women with GDM as diagnosed by the
Australasian Diabetes in Pregnancy Society criteria [16]
(75 g OGTT: fasting glucose >5.5 mmol/L; 2 h glucose
>8.0 mmol/L) in their 28-week OGTT were recruited.
All were negative for GAD antibodies, except for one
Copyright  2005 John Wiley & Sons, Ltd.
K. A. McLachlan et al.
subject who had a normal OGTT postpartum. Seven
GDM subjects were on insulin treatment at the time
of the pregnancy studies, the remainder were controlled
on diet alone. Nineteen control women, pair matched
for BMI in pregnancy (±4 kg/m2 ) and age (±4 years)
and with no first-degree relative with diabetes, a history
of polycystic ovarian syndrome or previous GDM, were
recruited. Subjects were studied in the third trimester
of pregnancy (mean 34.0 ± 0.3 weeks’ gestation) and
at 4.0 ± 0.4 months’ postpartum. An additional GDM
and control subject were studied postpartum (as the
GDM subject declined to be studied in pregnancy,
but consented to the postpartum studies), therefore
n = 20 for the postpartum studies. All were Australian
of European descent. Of the 20 control subjects, 18
were breastfeeding at the time of the postpartum study,
compared to 14 of 20 GDM subjects. Six control women
were taking the progesterone-only pill, and one the
combined contraceptive pill; of the GDM women, four
were on progesterone-only preparations and one on the
combined pill. These differences were not statistically
significant. The studies were approved by the Research
and Ethics Committees of the hospitals, and all subjects
gave informed written consent.
Experimental design
The women fasted from 10 PM the night before, having
consumed three meals of >40-g carbohydrate the previous
day. The subjects were weighed, asked to rest on a
bed or chair and a vein in the antecubital fossa was
cannulated (‘Insyte’ 18 gauge, Becton Dickenson, Sydney,
Australia). In the postpartum studies, waist–hip ratio
(WHR) and percentage of fat by bioelectrical impedance
analysis were also measured. These measures of adiposity
were not utilized in the pregnant state because of their
unreliability during pregnancy. After resting, fasting blood
was taken and 0.3 g/kg of 50% dextrose was diluted half
by saline and administered intravenously over 1 min. A
maximum dose of 20 g was used during pregnancy and
25 g postpartum (in order to not overestimate the glucose
dose based on a late pregnancy weight) and the cannula
flushed with 20 mL of normal saline immediately after
the IV dextrose. Samples were drawn from the same
cannula at 2, 3, 4, 6, 8, 10, 15, 20, 30, 40, 60, 75, 90
and 120 min, with flushing of the cannula with 3 mL of
normal saline between each draw [17]. Samples were
placed into pre-chilled tubes (serum/EDTA for TNFα,
Ad, high sensitivity CRP (hsCRP), leptin and lipids; 4%
sodium fluoride 25 µL/mL blood for glucose and insulin),
centrifuged within 40 min and stored at −80 ◦ C until
time of assay. A standard 75-g OGTT was performed at
6–9 weeks postpartum in all subjects.
Methods
Plasma glucose was analysed by a glucose oxidase method
(YSI 1500 ‘Sidekick’ analyser), coefficient of variation
Diabetes Metab Res Rev 2006; 22: 131–138.
Adipocytokines in Pregnancy
(CV) 2.4%. Insulin was measured by RIA, with <1%
cross-reactivity to pro-insulin and CV of 8.7% at insulin
levels 6 mU/L, 4.3% at 20 mU/L and 3.5% at 30
mU/L. Plasma insulin antibodies were not present in
any samples. Samples were tested in duplicate in Ad,
TNFα and Leptin assays, with pregnant and postpartum
samples for each GDM subject and her respective control
performed in the same assay. Adiponectin was analysed
using a RIA (Linco Research, St Charles, USA); inter-
assay CV 4.6%. TNFα was measured using a sandwich
ELISA (Quantikine, R&D, Minneapolis, Minnesota), with
a sensitivity of 0.5 pg/mL. Precision was assessed using
Bland–Altman analysis: the limits of agreement of
duplicates were 0.001 ± 0.009 pg/mL 5 of 80 samples
fell outside these limits. Leptin was measured by RIA
(Linco Research, St Charles, USA), inter-assay CV 8.4%.
CRP was measured by high-sensitivity nephelometry
(Dade Behring BNII, Marburg, Germany); Intra-assay
CV 3.7%, inter-assay CV 6.5%. Lipids were measured
on a Roche Modular analyser using standard enzymatic,
colourimetric methods: cholesterol was measured using
cholesterol esterase and cholesterol oxidase, triglyceride
using the Roche lipoprotein lipase method and high-
density lipoprotein (HDL) using a homogeneous HDL-
cholesterol method.
Acute insulin release to glucose (AIRg) and SI
were calculated using Minmod [18]. Disposition index
(AIRg × SI) was calculated as an assessment of SI adjusted
AIRg. Kg (glucose disappearance) is equal to the slope
(×100) of the natural logarithm of glucose values from 10
to 40 min after glucose infusion. Our FSIVGTTs continued
for only 120 min because of the women’s comfort and
social needs, so the basal values for glucose and insulin
were used to create a 180-min time point, which allows
accurate estimation of SI by Minmod. This methodology
has been demonstrated to be valid in insulin-sensitive
individuals [19]. We also undertook further validation
studies in insulin-resistant individuals (10 relatives of
diabetic subjects before and after severe insulin resistance
was induced by serial dexamethasone doses [20]). The
120-min method correlated well with the standard 180-
min calculations both in the pre (r = 0.96, p < 0.001) and
post (r = 0.98, p < 0.001) dexamethasone studies; the
mean difference was −0.14 ± 0.17[mU/L]−1 × 10−4 , t-
value −0.84 (pre) and −0.10 ± 0.14[mU/L]−1 × 10−4 , t-
value −0.76 (post) and there was no error bias in its
calculation.
Statistics
Data for GDM versus control subjects and pregnancy
versus postpartum for each subject were analysed
using paired t−tests, with transformation of the data
where appropriate to normalize their distribution. The
Bonferonni correction was applied to these analyses,
so p < 0.025 was accepted as the level of significance
for the paired t-tests. For Pearson correlations and
linear multiple regression, data was transformed where
Copyright  2005 John Wiley & Sons, Ltd.
133
appropriate to normalize the distribution. For non-
parametric data (analysis of % change of SI, Triglycerides
and HDL), Spearman correlations were used. Four
subjects (two control and two GDM) who had extremely
low TNFα levels postpartum – giving very high values
for the Ad/TNFα ratio above five standard deviations
above the mean – were excluded from the analyses
involving correlations with Ad/TNFα. Statistical analysis
was performed using Minitab and SPSS for windows.
Statistical significance was taken at p < 0.05.
Results
During pregnancy, in both groups, SI was significantly
reduced and AIRg elevated compared to postpartum.
GDM subjects demonstrated significantly reduced AIRg,
but equivalent SI compared to their matched control
subjects (Table 1). In contrast, postpartum GDM subjects
showed defects in both disposition index and SI.
Adipocytokines and CRP in pregnancy
and postpartum: GDM versus control
subjects (Figure 1)
Serum TNFα was significantly higher in the pregnant
subjects with GDM compared to control subjects (2.6 ±
0.3 vs 1.9 ± 0.3 pg/mL, p = 0.01). TNFα was not higher
in the GDM subjects postpartum (2.0 ± 0.3 vs 1.4 ±
0.2 pg/mL, p = 0.2). In both groups combined, there
was a trend towards higher levels during pregnancy
(2.3 ± 0.2 vs 1.7 ± 0.2 pg/mL, p = 0.08).
Adiponectin levels were not significantly different
between GDM and matched control women either in
pregnancy (8.0 ± 0.8 vs 9.4 ± 0.8 µg/mL, p = 0.28) or
postpartum (7.6 ± 0.9 vs 8.6 ± 0.8 µg/mL, NS). There
was also no difference in either group, separately
or combined, between the pregnancy levels and the
postpartum levels (7.8 ± 1.10 vs 7.2 ± 1.1 µg/mL, NS).
The ratio of Ad/TNFα tended to be lower, but was
not significantly different between GDM and control
subjects either in pregnancy (3.78 ± 0.58 vs 5.21 ± 0.79,
p = 0.054) or postpartum (5.11 ± 1.21 vs 8.09 ± 1.23,
p = 0.07).
Plasma leptin was significantly higher in pregnancy
than postpartum in both groups (27.8 ± 2.4 vs 19.3 ± 2.1,
p < 0.001). Plasma leptin was higher in control subjects
compared to GDM in pregnancy, although this was of
borderline significance (32.2 ± 3.9 vs 23.0 ± 2.3 ng/mL,
p = 0.05). Postpartum, this trend remained, but was not
significant (21.7 ± 3.7 vs 16.9 ± 2.2 ng/mL, p = 0.14).
HsCRP levels were significantly higher for GDM
and control women during pregnancy (5.1 ± 0.7 vs
3.2 ± 0.6 mg/L, p < 0.001), but there was no significant
difference between groups either during pregnancy or
postpartum.
Diabetes Metab Res Rev 2006; 22: 131–138.
134 K. A. McLachlan et al.

Table 1. Pregnancy and postpartum intravenous glucose tolerance test (IVGTT) results and subject characteristics

Control subjects GDM subjects

Pregnancy (n = 19) Postpartum (n = 20) Pregnancy (n = 19) Postpartum (n = 20)

Age (years) 33 ± 1 33 ± 1 33 ± 1 33 ± 1
BMI (kg/m2 ) (range) 31.6 ± 1.3 (24.8–43.0) 28.2 ± 1.4∗ (20.0–36.8) 31.5 ± 1.3 (24.2–41.6) 28.1 ± 1.3∗ (20.1–40.8)
Waist–hip ratio – 0.78 ± 0.01 – 0.81 ± 0.01‡
% fat – 36.2 ± 1.8 – 36.6 ± 1.7
OGTT
Fasting glucose (mmol/L) 4.48 ± 0.09 4.53 ± 0.11 5.62 ± 0.29‡ 5.11 ± 0.15‡
2-h glucose (mmol/L) 5.70 ± 0.21 5.19 ± 0.20 8.80 ± 0.46‡ 7.04 ± 0.43‡ ∗
IVGTT data
SI ([mU/L]−1 min−1 ) 4.23 ± 0.54 13.77 ± 1.53∗ 4.28 ± 0.53 9.94 ± 1.50‡,†
AIRg (mU/L/min) 872 ± 113 461.3 ± 66.4∗ 521 ± 89‡ 301.6 ± 46.0∗
Disposition index 3094 ± 284 4934 ± 356∗ 2094 ± 361‡ 2603 ± 429‡
Lipids
Triglycerides (mmol/L) 2.4 ± 0.2 0.8 ± 0.1∗ 2.7 ± 0.3 1.10 ± 0.2∗
HDL (mmol/L) 1.6 ± 0.1 1.40 ± 0.1† 1.5 ± 0.1 1.4 ± 0.1
Total cholesterol (mmol/L) 7.4 ± 0.4 4.9 ± 0.2∗ 6.7 ± 0.4 5.0 ± 0.3∗

Data is expressed as mean ± standard error

∗ p < 0.001.
† p ≤ 0.005 for postpartum vs pregnant state within each group (excluding the extra subject added to each group postpartum).
‡ p < 0.025 for GDM vs control subjects.

12
p = 0.01
10
Adiponectin (µg/mL)

4.0
8
TNFα (pg/mL)

3.0
6
2.0 4

1.0 2

0.0 0

Preg PP Preg PP Preg PP Preg PP

Control GDM Control GDM

p = 0.05
p < 0.01
7 p = 0.01
p < 0.001
6 40
p = 0.01
hsCRP (mg/L)

5
Leptin (ng/mL)

30
4
3 20

2 10
1
0
0
Preg PP Preg PP Preg PP Preg PP

Control GDM Control GDM

Figure 1. Plasma TNFα, adiponectin, hsCRP and leptin during pregnancy (‘preg’: mean 34 weeks) and postpartum (‘PP’: mean
4 months) in GDM and control subjects mean ±: SEM are shown

Adipocytokines, CRP and insulin
sensitivity in pregnancy (Table 2)
TNFα levels in pregnancy did not correlate with
SI, fasting insulin(r = −0.22, p = 0.19), BMI or lipid
parameters. Adiponectin levels also did not correlate
with SI, BMI or lipid parameters, nor was the calculated
adiponectin/TNFα ratio associated with SI in pregnancy.
During pregnancy, leptin correlated with SI and BMI.
HsCRP was associated with BMI, but not with SI or the
lipid parameters.

Copyright  2005 John Wiley & Sons, Ltd. Diabetes Metab Res Rev 2006; 22: 131–138.
Adipocytokines in Pregnancy 135

Table 2. Univariate correlations for adiponectin, TNFα , adiponectin/TNFα , leptin and hsCRP with
metabolic parameters in all subjects

Adiponectin Adiponectin/TNFα Leptin HsCRP

(Ln) TNFα ∗ (Ln) (Ln) (Ln)

Pregnancy r = 0.080 −0.084 0.182 0.713 0.519

BMI p = 0.629 NS NS <0.001 0.001
SI (Ln) 0.212 −0.035 0.190 −0.413 −0.072
NS NS NS 0.01 NS
AIRg (Ln) −0.032 −0.352 −0.213 0.398 0.083
NS 0.030 NS 0.013 NS
Disposition index (SI × AIRg) 0.087 −0.33 0.282 0.073 0.04
NS 0.041 NS NS NS
TG −0.096 0.056 −0.028 0.058 −0.036
NS NS NS NS NS
HDL 0.006 0.044 0.061 −0.244 −0.167
NS NS NS NS NS
Kg 0.241 −0.098 0.136 −0.051 −0.090
NS NS NS NS NS
Postpartum −0.253 0.474 −0.551 0.838 0.600
BMI NS 0.002 0.001 <0.001 0.001
% fat (sqrt) −0.230 0.375 −0.434 0.782 0.553
NS 0.020 0.012 <0.001 0.001
WHR −0.233 0.374 −0.499 0.378 0.353
NS 0.021 0.003 0.018 0.028
SI (Ln) 0.384 −0.478 0.616 −0.611 −0.479
0.014 0.002 0.001 <0.001 0.002
AIRg (Ln) −0.036 −0.055 0.123 0.261 0.033
NS NS NS NS NS
Disposition index (SI∗ AIRg) 0.277 −0.294 −0.553 −0.171 −0.352
NS 0.069 0.001 NS 0.026
TGs (Ln) −0.301 0.562 −0.578 0.383 0.295
0.059 0.001 0.001 0.015 0.065
HDL 0.294 −0.418 0.601 −0.607 −0.369
0.065 0.008 0.001 <0.001 0.019
Kg (Ln) 0.382 −0.136 0.531 −0.163 −0.411
0.015 NS 0.001 NS 0.008

BMI, body mass index; SI, insulin sensitivity; AIRg, acute insulin release; TG, triglycerides; HDL, high-density lipoproteins;
Kg, glucose disappearance; WHR, waist-hip ratio.
∗ TNFα values were transformed postpartum to normalize the distribution by square root.

Adipocytokines, CRP and insulin TG and the lesser the elevation HDL during pregnancy
sensitivity postpartum (Table 2) (% change SI and % change TG: r = −0.60, p < 0.001; %
change SI and % change HDL: r = 0.39, p = 0.02). There
In contrast to the situation in pregnancy, postpartum was no association between % change SI and % changes
to TNFα, adiponectin, hsCRP or leptin
TNFα correlated negatively with SI and HDL and
positively with fasting insulin, BMI, % fat and WHR.
Postpartum adiponectin levels correlated significantly
Adipocytokines and insulin secretion
with SI and fasting insulin (r = −0.34, p = 0.03); there
was a trend for an association with HDL and TG, but none
(Table 2)
for BMI, WHR or % fat. The adiponectin/TNFα ratio was
There was a negative correlation between TNFα and
significantly associated with SI and its related parameters.
AIRg, and between TNFα and the AIRg corrected for
Postpartum leptin was associated with SI, fasting
SI (disposition index) for all subjects during pregnancy.
insulin (r = 0.65, p < 0.001), BMI, % fat, HDL and
Postpartum, these associations were not present. In
TG. HsCRP was associated with SI, fasting insulin
GDM subjects alone, however, TNFα correlated with
(r = 0.45, p = 0.004), BMI, % fat, WHR and HDL.
the disposition index both in pregnancy (r = −0.46, p <
Although all of the cytokines examined were associated
0.05) and postpartum (r = −0.50, p = 0.02).
with postpartum SI, the only independent predictors of
SI were TG, HDL, leptin and GDM status, with an r2
of 68% for this linear regression model. In contrast, in
pregnancy, only leptin retained a significant association Discussion
with SI (leptin and SI: r = −0.41, p = 0.01).
There was an association for the pregnancy-induced This study examined whether four factors (adiponectin,
changes (expressed as % change) between TG and HDL TNFα, leptin and hsCRP) with associations to insulin
with SI for each individual – such that the greater the sensitivity were altered in pregnancy and whether they
drop in SI during pregnancy, the greater the elevation in could be related to the changes of insulin resistance or

Copyright  2005 John Wiley & Sons, Ltd. Diabetes Metab Res Rev 2006; 22: 131–138.
136
insulin secretion of pregnancy, particularly in women
with GDM.
Adipocytokine and CRP levels in
pregnancy and postpartum
In the pregnant state, TNFα levels were elevated, in
accordance with previous literature [3,4,21]. TNFα was
further elevated in pregnant GDM compared to their BMI-
matched pregnant control subjects. This is also consistent
with previous findings [3,4], although, to our knowledge,
this is the first study to document higher TNFα levels
in GDM pregnancies compared to a closely BMI-matched
group of healthy control women.
No significant change in adiponectin values from the
third trimester to four months postpartum emerged,
consistent with another recent study [22]. Our GDM
subjects did not have significantly different adiponectin
levels to the controls, although there was a slight trend
for the healthy control women to have higher levels
postpartum.
Our finding of elevated leptin in pregnancy may be due
to increased secretion from adipocytes in the presence
of elevated oestrogen [23] and placental production
[24], and is consistent with previous reports [15,25].
We observed reduced leptin levels in GDM compared to
that in control subjects. Reports of leptin levels in GDM
pregnancy are conflicting, with investigators reporting
similar [14], reduced [15] and elevated [13] leptin levels
in GDM women compared to healthy pregnancy controls.
HsCRP is an acute phase reactant, elevated levels
of which are associated with features of the metabolic
syndrome [26], and have also been documented to be
elevated in pregnancy [27]. Previous reports have shown
that where BMI and adiposity are taken into account,
hsCRP is not significantly associated with GDM [28,29].
Our finding in closely BMI-matched subjects confirms that
hsCRP is linked to adiposity, but not glucose tolerance, in
GDM women. There was no association with SI suggesting
that the elevation of hsCRP observed is not an important
cause or consequence of the reduction of SI in pregnancy.
Adipocytokines and CRP: relationship
to insulin sensitivity
In the postpartum state, all of the adipocytokines studied
demonstrated their expected association with SI, which
confirms the robust nature of our methodology with
pregnant and postpartum samples for each subject
measured in the same assay.
In pregnancy, only leptin retained a relationship with
SI, an association that has been noted previously [3],
although it remains unknown if leptin has a direct effect
on SI in pregnancy.
In contrast to previous investigators, we did not
observe an association between TNFα and SI during
pregnancy in either GDM or control women, though
Copyright  2005 John Wiley & Sons, Ltd.
K. A. McLachlan et al.
this relationship was apparent postpartum. Kirwan et al.
noted a correlation between TNFα and SI in a group of 15
women in the third trimester, divided equally into lean
normal glucose tolerant (NGT), obese NGT and GDM
groups [3]. The explanation for the difference in our
findings and those of Kirwan et al. may lie in the BMI
range of subjects tested. Our GDM and control subjects
with an average postpartum BMI of 28 kg/m2 correspond
to the five GDM subjects (BMI 30.8 kg/m2 ) and five
obese NGT subjects (BMI 27.3 kg/m2 ) respectively in
the study by Kirwan et al. where the serum TNFα
was not significantly different (2.84 ± 0.17 vs 2.80 ±
0.72 pg/mL), despite a difference in SI (4.9 ± 0.8 vs
9.5 ± 1.510−2 mg/kg FFM/min/µU/mL). It appears that
the association between TNFα and SI in pregnancy is
less evident in this overweight group of subjects. A
cross-sectional study by Winkler et al [4], who found
an association between fasting C-peptide and TNFα also
tested a leaner group of women, and this relationship
was not apparent on multivariate analysis once BMI was
accounted for, which is in keeping with our findings.
In our subjects there, was no association between
adiponectin and SI in pregnancy, which is consistent
with Ranheim et al. who reported no correlation between
Adiponectin and fasting insulin during pregnancy in 51
pregnant women [6]. In contrast, Cseh et al [7] found
reduced adiponectin levels in the second and third
trimester compared to the first trimester in a cross-
sectional study of healthy pregnant non-diabetic subjects.
They postulated that reduced adiponectin has a role in
the insulin resistance of pregnancy and especially of GDM
where they found further reductions. Our prospective
study does not suggest such a role for adiponectin.
Our observation of reduced SI in former GDM women
postpartum is in keeping with the findings reported by
previous investigators [9,30], and, given the association
of adiponectin with SI, one would expect that, in a larger
sample, GDM women would have statistically significantly
reduced adiponectin levels. Indeed, a recent study of 180
women found reduced adiponectin levels in GDM [12].
However, we would speculate that this was due to their
underlying lower insulin sensitivity in the non-pregnant
state rather than changes in pregnancy, as suggested by
Winzer et al’s study of 89 former GDM subjects [31]. Our
paired pregnant and postpartum data highlights that the
association of adiponectin with SI in pregnancy is weaker
than that observed postpartum.
Adiponectin and TNFα produce opposite effects on
insulin signalling – with TNFα inhibiting [32] and
adiponectin increasing [33] tyrosine phosphorylation of
the insulin receptor. TNFα may inhibit the synthesis
of adiponectin [5]. The ratio of these cytokines may
therefore be an important determinant of insulin
sensitivity. In our subjects, postpartum adiponectin/TNFα
correlated with SI and its related parameters of TG, HDL,
% fat and BMI, and had a higher correlation with SI than
either adiponectin or TNFα alone.
Lactation and the oral contraceptive pill use (by
a minority of subjects) may have had an impact on
Diabetes Metab Res Rev 2006; 22: 131–138.
Adipocytokines in Pregnancy
adiponectin levels and SI in our subjects. Combs et al.
noted an inhibitory effect of prolactin and oestrogen on
adiponectin levels in mice [34], which may be important
in our study given that 32/40 subjects were lactating at the
time of the postpartum study. However, the adiponectin
levels were consistent with previous studies for women
[35,36] and we found no evidence of altered adiponectin
levels in the non-breastfeeding subjects (non-lactating:
mean adiponectin 6.9 ± 1.7 vs lactating 8.4 ± 0.6µg/mL,
p = NS).
There are profound alterations in lipid levels during
normal pregnancy. Under the influence of elevated oestra-
diol, TG, HDL and cholesterol synthesis are stimulated
and levels increase by 200–310%, 15–40% and 30–65%
respectively [37,38]. The normal relationships between
plasma TG, HDL and SI are to some extent modulated
by these hormonal influences. However, our finding of an
association between the changes in HDL and TG with the
changes in SI indicates that there is still an influence of
SI on HDL and TG in pregnancy. The question then arises
as to whether this relationship may exist for the adipocy-
tokines. There was no association, however, between %
change TNFα, adiponectin or leptin with change in SI for
each individual, which suggests that in our study popula-
tion neither TNFα nor adiponectin are responding to or
driving the changes in SI during pregnancy.
Adipocytokines and CRP: relationship
to insulin secretion
In GDM subjects, the physiological decrease in SI
in pregnancy may unmask an abnormality in glucose
metabolism, which is not apparent in the non-pregnant
state. Thus, it is the defect in insulin secretion, which
differentiates those women who develop GDM from those
who maintain normal glucose tolerance [39]. A novel
finding of this study was the association between serum
TNFα and acute insulin secretion – AIRg. In pregnancy,
for all subjects, TNFα correlated with AIRg, although this
only remained significant for the GDM group postpartum.
Furthermore, for GDM subjects, there was a significant
association between TNFα and disposition index in
pregnancy. This raises the possibility that in pregnancy
TNFα could be having a deleterious impact on insulin
secretion in GDM subjects. This concept is supported by
in vitro evidence of a TNFα inhibiting beta cell function
[40,41].
We also observed an association between serum leptin
levels and AIRg for control subjects in pregnancy and
postpartum. This is most likely due to leptin’s close
association with BMI and SI – which, because of the
inverse relationship between AIRg and SI in normal
subjects, will produce an association between leptin and
AIRg. This was not seen in GDM subjects, where their
insulin secretory deficit has uncoupled the association
between AIRg and SI.
In conclusion, our findings suggest that adiponectin,
TNFα and hsCRP do not appear to contribute greatly
Copyright  2005 John Wiley & Sons, Ltd.
137
to pregnancy-induced insulin resistance in GDM or in
women with a healthy pregnancy, while leptin retains its
association with SI during pregnancy. TNFα is elevated in
GDM pregnancy, and may play a role in impairing insulin
secretion in these subjects.
Acknowledgements
This work was supported by the National Health and Medical
Research Council of Australia, the Medical Research Foundation
for Women and Babies, Cardiovascular Lipid research grant and
a Novo Nordisk Regional Diabetes Support Scheme Grant. The
authors also thank our research nurse Noella Johnson, Dr Kevin
Rowley for statistical advice and the women who participated.
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