Maternal fatty acid levels during pregnancy,
childhood lung function and atopic diseases.
The Generation R Study.
Running title: Prenatal fatty acid levels, childhood lung function and atopic diseases
Supplementary material
Emanuela Rucci, MD, MSc1,2,3, Herman T. den Dekker, MD1,2,3, Johan C. de Jongste, MD,
PhD2, Jolien Steenweg - de Graaff, MSc1,4, Romy Gaillard, MSc1,3,5, Suzanne G. Pasmans,
MD, PhD6, Albert Hofman, MD, PhD3, Henning Tiemeier, MD, PhD3,4,7,
Vincent W.V. Jaddoe, MD, PhD1,3,5, Liesbeth Duijts, MD, PhD2,3,8
1
The Generation R Study Group, 2Department of Pediatrics,
Division of Respiratory Medicine, 3Department of Epidemiology, 4
Department of Child and Adolescent Psychiatry/Psychology, 5Department of Pediatrics,
6
Department of Dermatology, 7Department of Psychiatry,
8
Department of Pediatrics, Division of Neonatology,
Erasmus MC, University Medical Center Rotterdam, The Netherlands
1
Supplementary Table 1. Comparison of the maternal and child characteristics
between those included in the study and lost to follow-up.
Included
Lost to follow-up
(n = 4,976)
(n = 977)
30.5 (4.9)
27.9 (5.5)
-
0.1 (1)
23.7 (18.7-35.7)
24.0 (18.4-37.8)
0.7 (34)
0.6 (6)
P-value
Maternal characteristics
Age at enrolment (years)
Missing
Pre-pregnancy body mass index (kg/m 2) *
Missing
Educational level (%)
<0.05
<0.05
<0.05
Primary, or secondary
51.5 (2,422)
76.7 (666)
Higher
48.5 (2,285)
23.3 (202)
Missing
5.4 (269)
11.2 (109)
Parity (%)
<0.05
0
57.4 (2,842)
51.9 (500)
≥1
42.6 (2,105)
48.1 (464)
Missing
0.6 (29)
1.3 (13)
History of asthma or atopy (%)
-
No
63.0 (2,742)
66.4 (557)
Yes
37.0 (1,613)
33.6 (282)
Missing
12.5 (621)
14.1 (138)
17.5 (5.8-37.8)
13.1 (4.8-37.2)
25.5 (1,269)
33.6 (328)
2,058 (553)
1,993 (607)
20.4 (1,016)
34.8 (340)
0.2 (0.0-1.3)
0.2 (0.0-1.5)
16.9 (842)
32.5 (318)
Folic acid level in 1st trimester of pregnancy (nmol/l) *
Missing
Total daily energy intake in 1st trimester of pregnancy (kcal)
Missing
Psychological distress (global severity index) *
Missing
Smoking during pregnancy (%)
<0.05
<0.05
<0.05
<0.05
No
83.4 (3,707)
74.7 (649)
Yes
16.6 (737)
25.3 (220)
Missing
10.7 (532)
11.1 (108)
20.7 (1.2)
20.7 (1.3)
-
-
Gestational age at PUFA blood sampling (weeks)
Missing
-
Child characteristics
Sex (%)
-
Male
49.9 (2,481)
52.9 (517)
Female
50,1 (2,495)
47.1 (460)
Missing
-
-
40.1 (35.9-42.4)
40.0 (34.9-42.4)
Gestational age at birth (weeks)*
2
<0.05
Missing
Birth weight (grams)
Missing
-
0.1(1)
3,442 (555)
3,369 (574)
0.2 (8)
0.3 (3)
Ethnicity (%)
<0.05
European
67.3 (3,227)
48.4 (433)
Non-European
32.7 (1,570)
51.6 (462)
Missing
3.6 (179)
8.4 (82)
Breastfeeding in the first year (%)
<0.01
No
7.5 (302)
10.1 (56)
Yes
92.5 (3,698)
89.9 (496)
Missing
19.6 (976)
43.5 (425)
Pet keeping in the first year (%)
-
No
66.9 (2,863)
67.0 (547)
Yes
33.1 (1,415)
33.0 (270)
Missing
14.0 (698)
16.4 (160)
7.3 (2.7-15.6)
8.2 (2.4-21.4)
50.5 (2,515)
78.1 (763)
6.0 (5.6-7.9)
6.1 (5.4-8.1)
6.9 (344)
79.2 (774)
PUFA intake age 14 months (g/day) *
Missing
Age at atopic outcomes follow-up (years) *
Missing
Lower respiratory infections age 6 years (%)
95.4 (4,044)
95.7 (201)
Yes
4.6 (196)
4.3 (9)
Missing
14.8 (736)
78.5 (767)
Inhalant allergies age 6 years (%)
-
No
93.6 (3,901)
91.8 (191)
Yes
6.4 (267)
8.2 (17)
16.2 (808)
78.7 (769)
15.8 (13.6-21.2)
16.2 (13.6-22.9)
7.0 (348)
79.3 (775)
Missing
(kg/m2)
<0.05
-
No
Body mass index age 6 years
<0.05
*
Missing
<0.05
Values are means (SD), *medians (2.5-97.5th percentile), or percentages (absolute numbers) based
on original data. P for difference was calculating using Student’s t-test for continuous variables,
Mann-Whitney U-test for continuous not normal distributed variables, and chi-square test for
categorical variables.
3
Supplementary Table 2. Association of maternal plasma glycerophospholipid n-6 PUFA levels (change in SDS) with Rint, FeNO,
current asthma and eczema in children aged 6 years.
Rint
FeNO
Current asthma
Current eczema
Z-score (95% CI)
Sym% (95% CI)
Odds ratio (95% CI)
Odds ratio (95% CI)
(n = 3,236)
(n = 2,955)
(n = 3,651)
(n = 3,693)
Basic model
0.06 (-0.04, 0.17)
0.03 (0.01, 0.05)**
1.04 (0.87, 1.24)
1.20 (1.11, 1.30)**
Confounder model
0.08 (-0.03, 0.19)
0.02 (0.00, 0.05)
0.95 (0.79, 1.15)
1.08 (0.99, 1.18)
Final model
0.08 (-0.03, 0.19)
0.02 (0.00, 0.05)
0.98 (0.78, 1.22)
1.10 (1.00, 1.20)*
Basic model
-0.15 (-0.25, -0.04)**
-0.01 (-0.03, 0.01)
1.14 (0.97, 1.35)
1.06 (0.98, 1.15)
Confounder model
-0.15 (-0.26, -0.04)**
0.00 (-0.03, 0.02)
1.06 (0.88, 1.27)
1.05 (0.97, 1.14)
Final model
-0.15 (-0.25, -0.05)**
-0.01 (-0.03, 0.02)
1.04 (0.84, 1.29)
1.02 (0.94, 1.12)
Basic model
0.08 (-0.02, 0.19)
0.03 (0.01, 0.05)**
0.98 (0.82, 1.17)
1.09 (1.01, 1.18)*
Confounder model
0.09 (-0.02, 0.19)
0.02 (0.00, 0.05)*
0.92 (0.76, 1.10)
1.02 (0.94, 1.11)
Final model
0.09 (-0.02, 0.20)
0.02 (0.00, 0.05)
0.93 (0.75, 1.16)
1.02 (0.93, 1.11)
Basic model
-0.13 (-0.24, -0.03)*
-0.01 (-0.04, 0.01)
0.89 (0.74, 1.06)
1.00 (0.92, 1.09)
Confounder model
-0.16 (-0.27, -0.05)**
-0.01 (-0.03, 0.01)
0.90 (0.75, 1.09)
1.04 (0.95, 1.13)
Final model
-0.15 (-0.26, -0.04)**
-0.01 (-0.04, 0.01)
0.85 (0.68, 1.06)
1.01 (0.93, 1.11)
Linoleic acid (C18:2n-6)
γ-Linolenic acid (C18:3n-6)
Eicosadienoic acid (C20:2n-6)
Dihomo-γ-Linolenic acid (C20:3n-6)
Arachidonic acid (C20:4n-6)
4
Basic model
-0.01 (-0.12, 0.09)
0.00 (-0.02, 0.02)
1.04 (0.87, 1.24)
1.09 (1.01, 1.19)*
Confounder model
0.01 (-0.10, 0.12)
0.00 (-0.03, 0.02)
0.95 (0.79, 1.15)
1.01 (0.92, 1.10)
Final model
-0.01 (-0.12, 0.11)
0.00 (-0.03, 0.02)
0.98 (0.78, 1.24)
1.01 (0.92, 1.10)
Basic model
-0.06 (-0.16, 0.05)
-0.01 (-0.03, 0.01)
1.14 (0.97, 1.35)
1.11 (1.02, 1.20)*
Confounder model
-0.06 (-0.17, 0.04)
-0.02 (-0.04, 0.01)
1.06 (0.88, 1.27)
1.01 (0.92, 1.10)
Final model
-0.06 (-0.17, 0.04)
-0.02 (-0.04, 0.01)
1.04 (0.84, 1.29)
1.00 (0.92, 1.10)
Basic model
-0.02 (-0.13, 0.08)
-0.01 (-0.03, 0.02)
0.98 (0.82, 1.17)
1.07 (0.98, 1.16)
Confounder model
-0.03 (-0.14, 0.08)
-0.01 (-0.04, 0.01)
0.92 (0.76, 1.10)
1.00 (0.92, 1.09)
Final model
-0.03 (-0.14, 0.08)
-0.01 (-0.04, 0.01)
0.93 (0.75, 1.16)
0.99 (0.91, 1.08)
Basic model
0.07 (-0.03, 0.17)
0.02 (0.00, 0.03)*
0.89 (0.74, 1.06)
1.05 (0.97, 1.14)
Confounder model
0.07 (-0.04, 0.18)
0.02 (0.00, 0.04)
0.90 (0.75, 1.09)
1.03 (0.94, 1.12)
Final model
0.07 (-0.03, 0.18)
0.02 (0.00, 0.04)
0.85 (0.68, 1.06)
1.04 (0.95, 1.14)
Adrenic acid (C22:4n-6)
Osbond acid (C22:5n-6)
LA/unsaturated metabolic products
Values are z-score changes in Rint, sympercent changes (sym%) in FeNO, and odds ratios (95% confidence interval) for current asthma and eczema from
linear and logistic intermediate regression models per standard deviation score (SDS) increase of maternal plasma glycerophospholipid n-6 PUFA levels
during pregnancy. “n =” represents number of total group. *p < 0.05 and **p < 0.01. The basic model was adjusted for maternal gestational age at blood
sampling for fatty acid levels, child’s sex and age at follow-up. The confounder model comprised the basic model and was additionally adjusted for maternal
age, pre-pregnancy body mass index, educational level, parity, history of asthma or atopy, folic acid levels and total daily calorie intake in the first trimester of
pregnancy, psychological distress and smoking during pregnancy, child’s ethnicity and pet keeping. The final model comprised the confounder model and
5
was additionally adjusted for child’s gestational age at birth, birth weight, breastfeeding, lower respiratory infection, inhalant allergies and body mass index at
age 6 years.
6
Supplementary Table 3. Association of maternal plasma glycerophospholipid n-3 PUFA levels (change in SDS) with Rint, FeNO,
current asthma and eczema in children aged 6 years.
Rint
FeNO
Current asthma
Current eczema
Z-score (95% CI)
Sym% (95% CI)
Odds ratio (95% CI)
Odds ratio (95% CI)
(n = 3,236)
(n = 2,955)
(n = 3,651)
(n = 3,693)
Basic model
0.02 (-0.08, 0.13)
-0.02 (-0.04, 0.00)
1.07 (0.90, 1.27)
0.96 (0.88, 1.04)
Confounder model
0.03 (-0.08, 0.14)
-0.01 (-0.03, 0.01)
1.13 (0.95, 1.36)
1.05 (0.96, 1.15)
Final model
0.03 (-0.08, 0.14)
-0.01 (-0.03, 0.01)
1.14 (0.92, 1.40)
1.05 (0.96, 1.15)
Basic model
-0.02 (-0.12, 0.09)
-0.02 (-0.04, 0.01)
1.00 (0.84, 1.18)
0.84 (0.77, 0.91)**
Confounder model
-0.02 (-0.13, 0.08)
-0.01 (-0.03, 0.01)
1.04 (0.88, 1.24)
0.90 (0.83, 0.98)*
Final model
-0.02 (-0.12, 0.09)
-0.01 (-0.04, 0.01)
1.08 (0.88, 1.33)
0.92 (0.84, 1.00)
Basic model
0.02 (-0.08, 0.13)
-0.02 (-0.05, 0.0)*
1.07 (0.91, 1.25)
0.83 (0.76, 0.91)**
Confounder model
0.03 (-0.09, 0.14)
-0.02 (-0.04, 0.01)
1.15 (0.98, 1.35)
0.93 (0.85, 1.02)
Final model
0.03 (-0.08, 0.14)
-0.02 (-0.04, 0.01)
1.16 (0.95, 1.40)
0.94 (0.85, 1.03)
Basic model
-0.10 (-0.20, -0.01)
-0.02 (-0.05, 0.00)
0.94 (0.78, 1.12)
0.93 (0.86, 1.01)
Confounder model
-0.11 (-0.22, -0.00)*
-0.01 (-0.04, 0.01)
0.99 (0.83, 1.19)
1.01 (0.93, 1.10)
Final model
-0.10 (-0.21, -0.00)
-0.01 (-0.04, 0.01)
1.01 (0.82, 1.25)
1.04 (0.95, 1.13)
α-Linoleic acid (C18:3n-3)
Eicosatrienoic acid (C20:3n-3)
Eicosapentaenoic acid (C20:5n-3)
Docosapentaenoic acid (C22:5n-3)
7
Docosahexaenoic acid (C22:6n-3)
Basic model
-0.03 (-0.13, 0.08)
0.00 (-0.03, 0.02)
0.85 (0.71, 1.02)
0.89 (0.82, 0.97)**
Confounder model
0.03 (-0.14, 0.08)
0.00 (-0.03, 0.02)
0.92 (0.76, 1.12)
0.97 (0.89, 1.06)
Final model
-0.02 (-0.14, 0.09)
0.00 (-0.03, 0.02)
0.92 (0.73, 1.17)
0.99 (0.90, 1.08)
Basic model
0.06 (-0.05, 0.17)
-0.01 (-0.03, 0.02)
1.14 (0.97, 1.34)
1.05 (0.96, 1.13)
Confounder model
0.06 (-0.04, 0.17)
0.00 (-0.02, 0.02)
1.14 (0.96, 1.35)
1.06 (0.98, 1.16)
Final model
0.06 (-0.05, 0.17)
0.00 (-0.02, 0.02)
1.11 (0.90, 1.37)
1.05 (0.96, 1.15)
ALA/unsaturated metabolic products
Values are z-score changes in Rint, sympercent changes (sym%) in FeNO, and odds ratios (95% confidence interval) for current asthma and eczema from
linear and logistic regression models per standard deviation score (SDS) increase of maternal plasma glycerophospholipid n-3 PUFA levels during
pregnancy. “n =” represents number of total group. *p < 0.05 and **p < 0.01. The basic model was adjusted for maternal gestational age at blood sampling for
fatty acid levels, child’s sex and age at follow-up. The confounder model comprised the basic model and was additionally adjusted for maternal age, prepregnancy body mass index, educational level, parity, history of asthma or atopy, folic acid levels and total daily calorie intake in the first trimester of
pregnancy, psychological distress and smoking during pregnancy, child’s ethnicity and pet keeping. The final model comprised the confounder model and
was additionally adjusted for child’s gestational age at birth, birth weight, breastfeeding, lower respiratory infection, inhalant allergies and body mass index at
age 6 years.
8
Supplementary Table 4. Association of maternal plasma glycerophospholipid fatty acid levels (change in SDS) with Rint, FeNO,
Current Asthma and Current Eczema in children aged 6 years, from final model additionally adjusted for child`s PUFA dietary intake.
Rint
FeNO
Current asthma
Current eczema
Z-score (95% CI)
Sym% (95% CI)
Odds ratio (95% CI)
Odds ratio (95% CI)
(n = 1,578)
(n = 1,479)
(n = 2,069)
(n = 2,093)
Total PUFAs
-0.01 (-0.19, 0.16)
-0.01 (-0.04, 0.03)
0.71 (0.51, 0.99)*
1.16 (1.01, 1.32)**
Total n-6 PUFAs
-0.01 (-0.23, 0.22)
0.00 (-0.05, 0.04)
0.64 (0.42, 0.99)*
1.21 (1.02, 1.44)*
Linoleic acid (C18:2n-6)
0.09 (-0.07, 0.25)
0.01 (-0.02, 0.05)
0.84 (0.60, 1.16)
1.11 (0.98, 1.27)
γ-Linolenic acid (C18:3n-6)
-0.10 (-0.26, 0.05)
0.02 (-0.02, 0.05)
0.85 (0.62, 1.15)
1.00 (0.89, 1.13)
Eicosadienoic acid (C20:2n-6)
0.00 (-0.16, 0.17)
0.02 (-0.02, 0.05)
1.04 (0.76, 1.43)
1.05 (0.93, 1.20)
Dihomo-γ-Linolenic acid (C20:3n-6)
-0.20 (-0.37, -0.04)*
0.02 (-0.02, 0.05)
1.02 (0.74, 1.40)
1.02 (0.90, 1.16)
Arachidonic acid (C20:4n-6)
0.02 (-0.15, 0.19)
-0.01 (-0.04, 0.03)
0.93 (0.67, 1.29)
1.00 (0.88, 1.14)
Adrenic acid (C22:4n-6)
-0.09 (-0.26, 0.07)
-0.01 (-0.05, 0.02)
0.89 (0.64, 1.25)
1.01 (0.89, 1.14)
Osbond acid (C22:5n-6)
-0.04 (-0.20, 0.13)
-0.01 (-0.05, 0.03)
0.79 (0.96, 1.12)
0.98 (0.86, 1.11)
LA/unsaturated metabolic products
0.09 (-0.07, 0.25)
0.01 (-0.02, 0.05)
0.94 (0.68, 1.31)
1.05 (0.92, 1.19)
-0.10 (-0.30, 0.11)
-0.03 (-0.08, 0.01)
0.81 (0.54, 1.19)
1.06 (0.91, 1.24)
α-Linoleic acid (C18:3n-3)
0.02 (-0.15, 0.18)
-0.03 (-0.07, 0.00)
1.07 (0.78, 1.47)
0.99 (0.87, 1.12)
Eicosatrienoic acid (C20:3n-3)
-0.04 (-0.20, 0.13)
-0.02 (-0.05, 0.02)
1.38 (1.02, 1.87)*
0.87 (0.76, 0.99)*
Eicosapentaenoic acid (C20:5n-3)
0.01 (-0.14, 0.16)
-0.02 (-0.05, 0.01)
1.19 (0.93, 1.52)
0.91 (0.80, 1.04)
Docosapentaenoic acid (C22:5n-3)
-0.14 (-0.30, 0.01)
-0.02 (-0.06, 0.01)
1.01 (0.75, 1.37)
1.01(0.89, 1.15)
Docosahexaenoic acid (C22:6n-3)
-0.09 (-0.25, 0.07)
-0.02 (-0.06, 0.01)
0.93 (0.67, 1.29)
0.98 (0.86, 1.11)
ALA/unsaturated metabolic products
0.06 (-0.11, 0.23)
-0.01 (-0.05, 0.03)
1.05 (0.77, 1.43)
1.01 (0.89, 1.15)
0.12 (-0.06, 0.31)
0.03 ( 0.00, 0.07)
0.87 (0.59, 1.26)
1.10 (0.95, 1.26)
Total n-3 PUFAs
n-6/n-3 PUFA ratio
9
Values are z-score changes in Rint, sympercent changes (sym%) in FeNO, and odds ratios (95% confidence interval) for current asthma and eczema from
linear and logistic regression models per standard deviation score (SDS) increase of maternal plasma glycerophospholipid fatty acid (GP fatty acid) levels
during pregnancy. “n =” represents number of total group with available data on child`s PUFA dietary intake. Total PUFAs: total polyunsaturated fatty acids; n6 PUFAs: total n-6 polyunsaturated fatty acids; n-3 PUFAs: total n-3 polyunsaturated fatty acids. *p < 0.05 and **p < 0.01. The model was adjusted for
maternal gestational age at blood sampling for fatty acid levels, child’s sex and age at follow-up, maternal age, pre-pregnancy body mass index, educational
level, parity, history of asthma or atopy, folic acid levels and total daily calorie intake in the first trimester of pregnancy, psychological distress and smoking
during pregnancy, child’s ethnicity and pet keeping, child’s gestational age at birth, birth weight, breastfeeding, lower respiratory infection, inhalant allergies
and body mass index at age 6 years and child`s dietary PUFA intake.
10
Supplementary Figure 1. Flowchart of participants.
n = 8,097
Singleton live born children
participating at age 6 years follow-up
n = 2,144
Missing data on plasma
glycerophospholipid fatty acids
during pregnancy excluded
n = 5,953
Mothers with complete plasma
glycerophospholipid fatty acid
measurements in mid-pregnancy
n = 977
Missing data on all atopic related
outcomes excluded
n = 4,976
Children with any atopic related
outcome data available at age 6
years
Rint
FeNO
Current asthma
Current eczema
n = 3,236
n = 2,955
n = 3,651
n = 3,693
11