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Zhang CXW, Candia AA, Sferruzzi-Perri AN. Placental inflammation, oxidative stress, and fetal outcomes in maternal obesity. Trends Endocrinol Metab 2024; 35:638-647. [PMID: 38418281 DOI: 10.1016/j.tem.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 03/01/2024]
Abstract
The obesity epidemic has led to a growing body of research investigating the consequences of maternal obesity on pregnancy and offspring health. The placenta, traditionally viewed as a passive intermediary between mother and fetus, is known to play a critical role in modulating the intrauterine environment and fetal development, and we now know that maternal obesity leads to increased inflammation, oxidative stress, and altered placental function. Here, we review recent research exploring the involvement of inflammation and oxidative stress as mechanisms impacting the placenta and fetus during obese pregnancy. Understanding them is crucial for informing strategies that can mitigate the adverse health effects of maternal obesity on offspring development and disease risk.
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Affiliation(s)
- Cindy X W Zhang
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| | - Alejandro A Candia
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK; Institute of Health Sciences, University of O'Higgins, Santiago, Chile
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Fang H, Wang X, Wang Z, Ma X, Zhang L, Yang L. Modulation of PI3K/AKT/mTOR signaling pathway in the ovine liver and duodenum during early pregnancy. Domest Anim Endocrinol 2024; 89:106870. [PMID: 38954983 DOI: 10.1016/j.domaniend.2024.106870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Revised: 06/22/2024] [Accepted: 06/26/2024] [Indexed: 07/04/2024]
Abstract
The liver and intestine play a critical role in nutrient absorption, storage, and metabolism. The aim of this study was to evaluate expression pattern of phosphatidylinositol 3-kinase (PI3K)/AKT/mammalian target of the rapamycin (mTOR) signaling pathway that included PI3K, AKT1, mTOR, FoxO1, SREBP-1, PPARα, PTEN and FXR in the maternal liver and duodenum. Ovine livers and duodenums were sampled at day 16 of the estrous cycle, and at days 13, 16 and 25 of gestation, and RT-qPCR, western blot and immunohistochemistry analysis were used to detect mRNA and protein expression. The results showed that expression of PI3K, AKT1, p-mTOR, FoxO1, SREBP-1 and PTEN upregulated in the maternal liver, and PPARα upregulated in the duodenum. However, expression of FoxO1, SREBP-1 and PTEN in the duodenum downregulated during early pregnancy. In addition, expression levels of SREBP-1, PTEN and PPARα in the maternal liver, and PI3K in the duodenum peaked at day 13 of pregnancy. In addition, expression levels of PI3K, p-mTOR and FoxO1 in the liver, and AKT1 and p-mTOR in the duodenum peaked at day 16 of pregnancy. Nevertheless, expression levels of FXR both in the maternal liver duodenum downregulated at days 13 and 16 of pregnancy. In conclusion, early pregnancy regulated expression pattern of PI3K/AKT/mTOR signaling pathway in the ovine liver and duodenum in a pregnancy stage-specific and tissue-specific manner, which may be necessary for the adaptations in maternal hepatic nutrient metabolism and intestinal nutrient absorption early pregnancy.
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Affiliation(s)
- Hongxu Fang
- School of Life Sciences and Food Engineering, Hebei University of Engineering, No. 19 Taiji Road, Handan 056038, PR China
| | - Xinxin Wang
- School of Life Sciences and Food Engineering, Hebei University of Engineering, No. 19 Taiji Road, Handan 056038, PR China
| | - Zhongyue Wang
- School of Life Sciences and Food Engineering, Hebei University of Engineering, No. 19 Taiji Road, Handan 056038, PR China
| | - Xiaoxin Ma
- School of Life Sciences and Food Engineering, Hebei University of Engineering, No. 19 Taiji Road, Handan 056038, PR China
| | - Leying Zhang
- School of Life Sciences and Food Engineering, Hebei University of Engineering, No. 19 Taiji Road, Handan 056038, PR China
| | - Ling Yang
- School of Life Sciences and Food Engineering, Hebei University of Engineering, No. 19 Taiji Road, Handan 056038, PR China.
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Sahoo PK, Krishnamoorthy C, Wood JR, Hanson C, Anderson-Berry A, Mott JL, Natarajan SK. Palmitate induces integrated stress response and lipoapoptosis in trophoblasts. Cell Death Dis 2024; 15:31. [PMID: 38212315 PMCID: PMC10784287 DOI: 10.1038/s41419-023-06415-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 12/19/2023] [Accepted: 12/22/2023] [Indexed: 01/13/2024]
Abstract
Maternal obesity increases the risk of childhood obesity and programs the offspring to develop metabolic syndrome later in their life. Palmitate is the predominant saturated free fatty acid (FFA) that is transported across the placenta to the fetus. We have recently shown that saturated FFA in the maternal circulation as a result of increased adipose tissue lipolysis in third trimester of pregnancy induces trophoblast lipoapoptosis. Here, we hypothesized that palmitate induces integrated stress response by activating mitogen-activated protein kinases (MAPKs), endoplasmic reticulum (ER) stress and granular stress and lipoapoptosis in trophoblasts. Choriocarcinoma-derived third-trimester placental trophoblast-like cells (JEG-3 and JAR) referred as trophoblasts were exposed to various concentrations of palmitate (PA). Apoptosis was assessed by nuclear morphological changes and caspase 3/7 activity. Immunoblot and immunofluorescence analysis was performed to measure the activation of MAPKs, ER stress and granular stress response pathways. Trophoblasts exposed to pathophysiological concentrations of PA showed a concentration-dependent increase in trophoblast lipoapoptosis. PA induces a caspase-dependent trophoblast lipoapoptosis. Further, PA induces MAPK activation (JNK and ERK) via phosphorylation, and activation of ER stress as evidenced by an increased phosphorylation eIF2α & IRE1α. PA also induces the activation of stress granules formation. Two pro-apoptotic transcriptional mediators of PA-induced trophoblast lipoapoptosis, CHOP and FoxO3 have increased nuclear translocation. Mechanistically, PA-induced JNK is critical for trophoblast lipoapoptosis. However, PA-induced activation of ERK and stress granule formation were shown to be cell survival signals to combat subcellular stress due to PA exposure. In conclusion, PA induces the activation of integrated stress responses, among which small molecule inhibition of JNK demonstrated that activation of JNK is critical for PA-induced trophoblast lipoapoptosis and small molecule activation of stress granule formation significantly prevents PA-induced trophoblast lipoapoptosis.
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Affiliation(s)
- Prakash Kumar Sahoo
- Department of Nutrition and Health Sciences, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Chandan Krishnamoorthy
- Department of Nutrition and Health Sciences, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Jennifer R Wood
- Department of Animal Sciences, University of Nebraska-Lincoln, Lincoln, NE, USA
| | - Corrine Hanson
- College of Allied Health Professions Medical Nutrition Education, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ann Anderson-Berry
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA
| | - Justin L Mott
- Department of Biochemistry and Molecular Biology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sathish Kumar Natarajan
- Department of Nutrition and Health Sciences, University of Nebraska-Lincoln, Lincoln, NE, USA.
- College of Allied Health Professions Medical Nutrition Education, University of Nebraska Medical Center, Omaha, NE, USA.
- Department of Biochemistry, University of Nebraska-Lincoln, Lincoln, NE, USA.
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Robles M, Rousseau-Ralliard D, Dubois C, Josse T, Nouveau É, Dahirel M, Wimel L, Couturier-Tarrade A, Chavatte-Palmer P. Obesity during Pregnancy in the Horse: Effect on Term Placental Structure and Gene Expression, as Well as Colostrum and Milk Fatty Acid Concentration. Vet Sci 2023; 10:691. [PMID: 38133242 PMCID: PMC10748288 DOI: 10.3390/vetsci10120691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/22/2023] [Accepted: 11/24/2023] [Indexed: 12/23/2023] Open
Abstract
In horses, the prevalence of obesity is high and associated with serious metabolic pathologies. Being a broodmare has been identified as a risk factor for obesity. In other species, maternal obesity is known to affect the development of the offspring. This article is a follow-up study of previous work showing that Obese mares (O, n = 10, body condition score > 4.25 at insemination) were more insulin resistant and presented increased systemic inflammation during pregnancy compared to Normal mares (N, n = 14, body condition score < 4 at insemination). Foals born to O mares were more insulin-resistant, presented increased systemic inflammation, and were more affected by osteoarticular lesions. The objective of the present study was to investigate the effect of maternal obesity on placental structure and function, as well as the fatty acid profile in the plasma of mares and foals, colostrum, and milk until 90 days of lactation, which, to our knowledge, has been poorly studied in the horse. Mares from both groups were fed the same diet during pregnancy and lactation. During lactation, mares were housed in pasture. A strong heat wave, followed by a drought, occurred during their 2nd and 3rd months of lactation (summer of 2016 in the Limousin region, France). In the present article, term placental morphometry, structure (stereology), and gene expression (RT-qPCR, genes involved in nutrient transport, growth, and development, as well as vascularization) were studied. Plasma of mares and their foals, as well as colostrum and milk, were sampled at birth, 30 days, and 90 days of lactation. The fatty acid composition of these samples was measured using gas chromatography. No differences between the N and O groups were observed for term placental morphometry, structure, or gene expression. No difference in plasma fatty acid composition was observed between groups in mares. The plasma fatty acid profile of O foals was more pro-inflammatory and indicated an altered placental lipid metabolism between birth and 90 days of age. These results are in line with the increased systemic inflammation and altered glucose metabolism observed until 18 months of age in this group. The colostrum fatty acid profile of O mares was more pro-inflammatory and indicated an increased transfer and/or desaturation of long-chain fatty acids. Moreover, O foals received a colostrum poorer in medium-chain saturated fatty acid, a source of immediate energy for the newborn that can also play a role in immunity and gut microbiota development. Differences in milk fatty acid composition indicated a decreased ability to adapt to heat stress in O mares, which could have further affected the metabolic development of their foals. In conclusion, maternal obesity affected the fatty acid composition of milk, thus also influencing the foal's plasma fatty acid composition and likely participating in the developmental programming observed in growing foals.
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Affiliation(s)
- Morgane Robles
- BREED, Domaine de Vilvert, Université Paris Saclay, UVSQ, INRAE, 78350 Jouy en Josas, France; (D.R.-R.); (A.C.-T.)
- BREED, Ecole Nationale Vétérinaire d’Alfort, 94700 Maisons-Alfort, France
- Institut Polytechnique Unilasalle, 76130 Mont-Saint-Aignan, France
| | - Delphine Rousseau-Ralliard
- BREED, Domaine de Vilvert, Université Paris Saclay, UVSQ, INRAE, 78350 Jouy en Josas, France; (D.R.-R.); (A.C.-T.)
- BREED, Ecole Nationale Vétérinaire d’Alfort, 94700 Maisons-Alfort, France
| | - Cédric Dubois
- Institut Français du Cheval et de l’Equitation, Station Expérimentale de la Valade, 19370 Chamberet, France (L.W.)
| | - Tiphanie Josse
- BREED, Domaine de Vilvert, Université Paris Saclay, UVSQ, INRAE, 78350 Jouy en Josas, France; (D.R.-R.); (A.C.-T.)
- BREED, Ecole Nationale Vétérinaire d’Alfort, 94700 Maisons-Alfort, France
| | - Émilie Nouveau
- BREED, Domaine de Vilvert, Université Paris Saclay, UVSQ, INRAE, 78350 Jouy en Josas, France; (D.R.-R.); (A.C.-T.)
- BREED, Ecole Nationale Vétérinaire d’Alfort, 94700 Maisons-Alfort, France
| | - Michele Dahirel
- BREED, Domaine de Vilvert, Université Paris Saclay, UVSQ, INRAE, 78350 Jouy en Josas, France; (D.R.-R.); (A.C.-T.)
- BREED, Ecole Nationale Vétérinaire d’Alfort, 94700 Maisons-Alfort, France
| | - Laurence Wimel
- Institut Français du Cheval et de l’Equitation, Station Expérimentale de la Valade, 19370 Chamberet, France (L.W.)
| | - Anne Couturier-Tarrade
- BREED, Domaine de Vilvert, Université Paris Saclay, UVSQ, INRAE, 78350 Jouy en Josas, France; (D.R.-R.); (A.C.-T.)
- BREED, Ecole Nationale Vétérinaire d’Alfort, 94700 Maisons-Alfort, France
| | - Pascale Chavatte-Palmer
- BREED, Domaine de Vilvert, Université Paris Saclay, UVSQ, INRAE, 78350 Jouy en Josas, France; (D.R.-R.); (A.C.-T.)
- BREED, Ecole Nationale Vétérinaire d’Alfort, 94700 Maisons-Alfort, France
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Jo S, Alejandro EU. RISING STARS: Mechanistic insights into maternal-fetal cross talk and islet beta-cell development. J Endocrinol 2023; 259:e230069. [PMID: 37855321 PMCID: PMC10692651 DOI: 10.1530/joe-23-0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 10/18/2023] [Indexed: 10/20/2023]
Abstract
The metabolic health trajectory of an individual is shaped as early as prepregnancy, during pregnancy, and lactation period. Both maternal nutrition and metabolic health status are critical factors in the programming of offspring toward an increased propensity to developing type 2 diabetes in adulthood. Pancreatic beta-cells, part of the endocrine islets, which are nutrient-sensitive tissues important for glucose metabolism, are primed early in life (the first 1000 days in humans) with limited plasticity later in life. This suggests the high importance of the developmental window of programming in utero and early in life. This review will focus on how changes to the maternal milieu increase offspring's susceptibility to diabetes through changes in pancreatic beta-cell mass and function and discuss potential mechanisms by which placental-driven nutrient availability, hormones, exosomes, and immune alterations that may impact beta-cell development in utero, thereby affecting susceptibility to type 2 diabetes in adulthood.
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Affiliation(s)
- Seokwon Jo
- Department of Integrative Biology & Physiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Emilyn U Alejandro
- Department of Integrative Biology & Physiology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
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Álvarez D, Ortiz M, Valdebenito G, Crisosto N, Echiburú B, Valenzuela R, Espinosa A, Maliqueo M. Effects of a High-Fat Diet and Docosahexaenoic Acid during Pregnancy on Fatty Acid Composition in the Fetal Livers of Mice. Nutrients 2023; 15:4696. [PMID: 37960348 PMCID: PMC10649644 DOI: 10.3390/nu15214696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 10/27/2023] [Accepted: 11/03/2023] [Indexed: 11/15/2023] Open
Abstract
A high-fat diet (HFD) during pregnancy promotes fat accumulation and reduces docosahexaenoic acid (DHA) levels in the liver of the offspring at postnatal ages, which can depend on fetal sex. However, the prenatal mechanisms behind these associations are still unclear. Thus, we analyzed if an HFD alters DHA content and the expression of molecules related to fatty acid (FA) metabolism in the fetal liver. Female C57BL/6 mice were fed a control diet or HFD for 4-6 weeks before pregnancy until the gestational day (GD) 17.5. A subgroup of each diet received DHA (100 mg/Kg) orally from GD 6.5 until 16.5. On GD 17.5, maternal livers, placentas, and livers from male and female fetuses were collected for FA profiling with gas-chromatography and gene expression of molecules related to FA metabolism using qPCR. PPAR-α protein expression was evaluated using Western blot. The gene expression of placental FA transporters was also assessed. An HFD increased eicosapentaenoic acid (EPA) and decreased DHA levels and protein expression of PPAR-α in the fetal livers of both sexes. DHA increased the gene expression of Ppara, Cpt1, and Acsl1 in the livers of female fetuses. Therefore, an HFD reduces DHA levels and PPAR-α, a master regulator of gene expression, in the fetal liver. In turn, the livers of female fetuses seem to be more sensitive to DHA action.
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Affiliation(s)
- Daniela Álvarez
- Laboratory of Endocrinology and Metabolism, Department of Internal Medicine West Division, Universidad de Chile, Santiago 8350499, Chile; (D.Á.); (M.O.); (G.V.); (N.C.); (B.E.)
| | - Macarena Ortiz
- Laboratory of Endocrinology and Metabolism, Department of Internal Medicine West Division, Universidad de Chile, Santiago 8350499, Chile; (D.Á.); (M.O.); (G.V.); (N.C.); (B.E.)
| | - Gabriel Valdebenito
- Laboratory of Endocrinology and Metabolism, Department of Internal Medicine West Division, Universidad de Chile, Santiago 8350499, Chile; (D.Á.); (M.O.); (G.V.); (N.C.); (B.E.)
| | - Nicolás Crisosto
- Laboratory of Endocrinology and Metabolism, Department of Internal Medicine West Division, Universidad de Chile, Santiago 8350499, Chile; (D.Á.); (M.O.); (G.V.); (N.C.); (B.E.)
- Endocrinology Unit, Department of Medicine, Clínica Alemana de Santiago, Faculty of Medicine, Universidad del Desarrollo, Santiago 7610658, Chile
| | - Bárbara Echiburú
- Laboratory of Endocrinology and Metabolism, Department of Internal Medicine West Division, Universidad de Chile, Santiago 8350499, Chile; (D.Á.); (M.O.); (G.V.); (N.C.); (B.E.)
| | - Rodrigo Valenzuela
- Nutrition Department, School of Medicine, Universidad de Chile, Santiago 8380000, Chile;
| | - Alejandra Espinosa
- Department of Medical Technology, Faculty of Medicine, University of Chile, Santiago 8380453, Chile;
| | - Manuel Maliqueo
- Laboratory of Endocrinology and Metabolism, Department of Internal Medicine West Division, Universidad de Chile, Santiago 8350499, Chile; (D.Á.); (M.O.); (G.V.); (N.C.); (B.E.)
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Rasool A, Mahmoud T, O’Tierney-Ginn P. Lipid Aldehydes 4-Hydroxynonenal and 4-Hydroxyhexenal Exposure Differentially Impact Lipogenic Pathways in Human Placenta. BIOLOGY 2023; 12:biology12040527. [PMID: 37106728 PMCID: PMC10135722 DOI: 10.3390/biology12040527] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/16/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023]
Abstract
Long chain polyunsaturated fatty acids (LCPUFAs), such as the omega-6 (n-6) arachidonic acid (AA) and n-3 docosahexanoic acid (DHA), have a vital role in normal fetal development and placental function. Optimal supply of these LCPUFAs to the fetus is critical for improving birth outcomes and preventing programming of metabolic diseases in later life. Although not explicitly required/recommended, many pregnant women take n-3 LCPUFA supplements. Oxidative stress can cause these LCPUFAs to undergo lipid peroxidation, creating toxic compounds called lipid aldehydes. These by-products can lead to an inflammatory state and negatively impact tissue function, though little is known about their effects on the placenta. Placental exposure to two major lipid aldehydes, 4-hydroxynonenal (4-HNE) and 4-hydroxyhexenal (4-HHE), caused by peroxidation of the AA and DHA, respectively, was examined in the context of lipid metabolism. We assessed the impact of exposure to 25 μM, 50 μM and 100 μM of 4-HNE or 4-HHE on 40 lipid metabolism genes in full-term human placenta. 4-HNE increased gene expression associated with lipogenesis and lipid uptake (ACC, FASN, ACAT1, FATP4), and 4-HHE decreased gene expression associated with lipogenesis and lipid uptake (SREBP1, SREBP2, LDLR, SCD1, MFSD2a). These results demonstrate that these lipid aldehydes differentially affect expression of placental FA metabolism genes in the human placenta and may have implications for the impact of LCPUFA supplementation in environments of oxidative stress.
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Ortiz M, Sánchez F, Álvarez D, Flores C, Salas-Pérez F, Valenzuela R, Cantin C, Leiva A, Crisosto N, Maliqueo M. Association between maternal obesity, essential fatty acids and biomarkers of fetal liver function. Prostaglandins Leukot Essent Fatty Acids 2023; 190:102541. [PMID: 36736061 DOI: 10.1016/j.plefa.2023.102541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/13/2023] [Accepted: 01/15/2023] [Indexed: 01/18/2023]
Abstract
Maternal obesity and the imbalance in linoleic acid (C18:2 n-6, LA) and alpha-linolenic acid (C18:3 n-3, ALA) levels are related with hepatic disturbances in the offspring. However, whether these alterations are present during fetal life is not well understood. Obese and normal weight pregnant women were recruited to determine fatty acids (FAs) consumption, FAs profile (in maternal erythrocytes, placenta and neonatal very low-density lipoproteins VLDL) and biomarkers of fetal liver function, such as gamma-glutamyl transferase (GGT), alpha-fetoprotein (AFP) and albumin, in umbilical cord blood. Stearic acid (C18:0, ST) was lower, and total n-3 FAs tended to be lower in umbilical cord VLDLs of obese women compared to controls. Independently of maternal obesity, GGT levels in umbilical cord blood was positively correlated with the LA content and negatively correlated with the ALA content in maternal erythrocytes. We conclude that maternal obesity and its imbalance of LA and ALA are associated with changes in biomarkers of fetal liver function.
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Affiliation(s)
- Macarena Ortiz
- Laboratory of Endocrinology and Metabolism, Department of Medicine West Division, Universidad de Chile, Santiago, Chile
| | - Francisca Sánchez
- Laboratory of Endocrinology and Metabolism, Department of Medicine West Division, Universidad de Chile, Santiago, Chile
| | - Daniela Álvarez
- Laboratory of Endocrinology and Metabolism, Department of Medicine West Division, Universidad de Chile, Santiago, Chile
| | - Cristian Flores
- Laboratory of Endocrinology and Metabolism, Department of Medicine West Division, Universidad de Chile, Santiago, Chile
| | | | - Rodrigo Valenzuela
- Nutrition Department, School of Medicine, Universidad de Chile, Santiago, Chile
| | - Claudette Cantin
- School of Medical Technology, Faculty of Medicine and Science, Universidad San Sebastián, Santiago, Chile
| | - Andrea Leiva
- School of Medical Technology, Faculty of Medicine and Science, Universidad San Sebastián, Santiago, Chile
| | - Nicolás Crisosto
- Laboratory of Endocrinology and Metabolism, Department of Medicine West Division, Universidad de Chile, Santiago, Chile; Endocrinology Unit, Department of Medicine, Clínica Alemana de Santiago, Faculty of Medicine, Universidad del Desarrollo, Santiago, Chile
| | - Manuel Maliqueo
- Laboratory of Endocrinology and Metabolism, Department of Medicine West Division, Universidad de Chile, Santiago, Chile.
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