DOI: 10.1111/1471-0528.

12937 Maternal medicine

www.bjog.org

An explained variance-based genetic risk score

associated with gestational diabetes antecedent
and with progression to pre-diabetes and type 2
diabetes: a cohort study
H Cormier,a,b,* J Vigneault,a,b,* V Garneau,b A Tchernof,a,c M-C Vohl,a,b SJ Weisnagel,a,c
J Robitaillea,b
a
Department of Food Sciences and Nutrition, Laval University, Quebec City, QC, Canada b Institute of Nutrition and Functional Foods
(INAF), Laval University, Quebec City, QC, Canada c Endocrinology and Nephrology, CHU de Quebec Research Center, Quebec City, QC,
Canada
Correspondence: Dr J Robitaille, Department of Food Sciences and Nutrition, Institute of Nutrition and Functional Foods (INAF), Laval
University, Pavillon des services, 2440 Hochelaga Blvd, Room 2729-N, Quebec City, Quebec, Canada G1V 0A6. Email julie.robitaille@fsaa.ulaval.ca

Accepted 21 April 2014. Published Online 18 July 2014.

Objective To determine whether an explained-variance genetic
risk score (GRS), with 36 single nucleotide polymorphisms (SNPs)
previously associated with type 2 diabetes (T2D), is also associated
with gestational diabetes mellitus (GDM), and with the
progression to pre-diabetes and T2D among women with prior
GDM.
Design A cohort study.
Setting Clinical investigation unit of Laval University, Quebec,
Canada.
Population A cohort of 214 women with prior GDM and 82
controls recruited between 2009 and 2012.
Methods Associations between the GRS and GDM.
Main outcomes measures GDM and prevalence of pre-diabetes
and T2D.
Results Women with prior GDM had a higher GRS compared
with controls (38.6  3.9, 95% CI 38.1–39.1, versus 37.4  3.2,
95% CI 36.7–38.1; P < 0.0001). In women with prior GDM, the
explained-variance GRS was higher for pre-diabetic women
compared with women who remained normoglucotolerant at
testing (1.21  0.18, 95% CI 1.18–1.23, versus 1.17  0.15, 95%
CI 1.13–1.20; P < 0.0001). Similarly, women with T2D had a
higher explained-variance GRS compared with women with prior
GDM who remained normoglucotolerant (1.20  0.18, 95% CI
1.14–1.25, versus 1.17  0.17, 95% CI 1.13–1.20; P < 0.0001).
The predictive effects of the explained-variance GRS, age, and
body mass index (BMI), or the additive effects of the three
variables, were tested for pre-diabetes and T2D. We observed an
area under the curve of 0.6269 (95% CI 0.5638–0.6901) for age
and BMI, and adding the explained-variance GRS into the model
increased the area to 0.6672 (95% CI 0.6064–0.7281) for the
prediction of pre-diabetes.
Conclusions An explained-variance GRS is associated with both
GDM and progression to pre-diabetes and T2D in women with
prior GDM.
Keywords Genetic risk score, gestational diabetes mellitus,
susceptibility genes, type 2 diabetes.

Please cite this paper as: Cormier H, Vigneault J, Garneau V, Tchernof A, Vohl M-C, Weisnagel SJ, Robitaille J. An explained variance-based genetic risk
score associated with gestational diabetes antecedent and with progression to pre-diabetes and type 2 diabetes: a cohort study. BJOG 2015;122:411–419.

complicated by GDM.2,3 GDM appears as a preview to

Introduction
Gestational diabetes mellitus (GDM) is defined as glucose
intolerance with first onset or recognition during preg-
nancy, and is characterised by impaired insulin secretion
and action.1 About one woman out of five has a pregnancy
*These authors contributed equally to this work.
important adverse metabolic complications in the years
following delivery, such as cardiovascular diseases and type
2 diabetes (T2D).2,4,5 Using population-based data, Feig
et al.2 observed that the prevalence of T2D after GDM
was 13.1 and 18.9% at 5.2 and 9.0 years after delivery,
respectively. A systematic review revealed that the cumula-

ª 2014 Royal College of Obstetricians and Gynaecologists 411

 Cormier et al.
tive incidence of T2D ranged from 2.6 to over 70.0% in
studies that examined women from 6 weeks to 28 years
postpartum.6
Gestational diabetes mellitus is recognised as a multifac-
torial disease in which it is likely that environment trig-
gers interact with genetic variants.7 Given that women
with prior GDM are at an increased risk of developing
T2D later in life,5 and that women with a family history
of T2D are at increased risk of GDM,8 it is possible to
hypothesise that GDM and T2D may share similar genetic
susceptibilities and risk factors.9–11 Genetic variants deter-
mining the risk of T2D may, therefore, also be associated
with GDM.
New genetic variants associated with susceptibility to
T2D have been discovered in recent genome-wide associa-
tion studies (GWAS).12,13 Advances in genetic knowledge
have demonstrated many new loci related with increased
T2D risk.14,15 The Diabetes Prevention Program showed
that a higher T2D genetic risk, estimated with a score from
34 single nuclear polymorphisms (SNPs) associated with
T2D, was also predictive of the progression to diabetes in
high-risk individuals.16
In the present study, genotype frequencies and effect
sizes of the SNPs in the diabetogenic genes were compared
in women with prior GDM and a control group of women
without GDM history. Our objective was to determine
whether a new explained-variance genetic risk score (GRS)
with 36 SNPs related to T2D is associated with antecedent
GDM, and whether this GRS is predictive of the subse-
quent development of pre-diabetes and T2D among women
with prior GDM. We hypothesised that a higher
explained-variance GRS, which includes T2D-related loci, is
also associated with prior GDM and predicts pre-diabetes
and T2D.
Methods
Participants and study design
The study population has been described previously.17
Briefly, a total of 296 women were recruited through access
to administrative data from the Regie de l’assurance mala-
die du Quebec (RAMQ), the provincial health plan registry.
Women living in the greater Quebec City area, aged
≥18 years, with a pregnancy between 2003 and 2010 were
invited to participate. Women were excluded if they were
pregnant at the time of the study or if they had type-I dia-
betes. A total of 3896 women were sent a letter. A total of
688 women contacted the research team, of whom 95 were
not eligible (pregnant at the time of the study or had type-I
diabetes) and 297 refused to participate. The study sample
thus consisted of 214 women with prior GDM and 82
women without prior GDM (controls), recruited between
October 2009 and August 2012. Women were tested at the
412
Clinical Investigation Unit at the Institute of Nutrition and
Functional Foods (INAF) of Laval University, Quebec,
Canada. All subjects gave their written consent and ethical
approval was obtained from the Laval University Ethics
Committee. This trial was registered at clinicaltrials.gov as
NCT01340924.
Data collection
Data have been carefully collected for each participant
using standardised procedures and validated tools. Weight
was measured to the nearest 0.1 kg on a calibrated balance,
height was measured to the nearest millimeter with a stadi-
ometer, and body mass index (BMI) was then calculated
(kg/m2).
Oral glucose tolerance test
A 75-g, 2-hour, oral glucose tolerance test (OGTT) was
performed in the morning after an overnight fast. Blood
samples were collected at 15, 0, 15, 30, 60, 90, and
120 minutes for the measurement of plasma glucose and
insulin levels. The interassay coefficient of variation for
the OGTT was 1.0% for a basal glucose value set at
5.0 mmol/l. Plasma glucose was measured enzymatically,18
whereas plasma insulin was measured by radioimmunoas-
say.19 Impaired fasting glucose was characterised by a
fasting glucose value of 6.1–7.0 mmol/l, and impaired
glucose tolerance was characterised by a normal fasting
glucose value (<6.1 mmol/l) and a 2-hour post-OGTT
glucose value of 7.8–11.1 mmol/l.20 The glycated haemo-
globin (A1C) was measured using Cobas Integra 800 and
standardised with the National Glycated Haemoglobin
Standardization Program (Integra Inc., Roche, Switzer-
land). In accordance with the 2013 Canadian Diabetes
Association latest guidelines, pre-diabetes was defined as
impaired fasting glucose, and/or impaired glucose toler-
ance, and/or A1C (between 6.0 and 6.4%). T2D was
defined as fasting plasma glucose ≥7.0 mmol/l, and/or
2-hour plasma glucose post-OGTT ≥ 11.1 mmol/l, and/or
A1C ≥ 6.5%.20
The homeostasis model assessment for insulin sensitivity
(HOMA-IS) index was calculated using the following for-
mula: (fasting insulin concentration 9 fasting glucose con-
centration)/22.5.21 The Matsuda index was calculated as
follows: 10 000/√[fasting glucose concentration 9 fasting
insulin concentration 9 (mean glucose 9 mean insulin)].22
The area under the curves for glucose and insulin excur-
sions after the glucose load were calculated using the trape-
zoidal rule.23 The insulin secretion index was estimated by
the ratio between the area under the curve for insulin and
the area under the curve for glucose.24 The insulinogenic
index for insulin secretion [(insulin at 30 minutes fasting
insulin)/(glucose at 30 minutes fasting glucose)] was also
calculated.25,26
ª 2014 Royal College of Obstetricians and Gynaecologists
 Genetic risk score in GDM and T2D

Selection of risk alleles rs10811661, rs7754840, rs1801282, rs1111875, rs1470579,

The GRS was assessed based on the 34 SNPs confirmed to
be associated with T2D in a previous study by Hivert
et al.16 on a population of European ancestry. We added
two SNPs, rs2237895 (KCNQ1) and rs12255372 (TCF7L2),
in the new explained-variance GRS model, which were pre-
viously found to be associated with GDM.11,27,28 As shown
in Table 1, to construct the explained-variance GRS model,
selected SNPs (rs2237895, rs12255372, rs7903146,
rs5219, rs13266634, rs7578597, rs1552224, rs10923931,
rs11708067, rs10010131, rs4747969, rs7578326, rs13292136,
rs864745, rs757210, rs1531343, rs4607103, rs7961581, rs10
830963, rs243021, rs231362, rs4457053, rs340874, rs917793,
rs972283, rs8042680, rs7957197, rs2191349, rs780094,
rs896854, and rs11634397) were genotyped using validated
primers and TaqMan probes (Life Technologies Corpora-
tion, Burlington, ON, Canada).29 DNA was mixed with

Table 1. Type 2 diabetes risk loci

Genes SNPs Alleles (risk/other) MAF* OR** Study Overall study

A, risk allele/a, other allele

AA Aa aa
n (%) n (%) n (%)

TCF7L2 rs7903146 T/C T = 0.40 1.37 DIAGRAM 41 (13.8) 154 (51.9) 102 (34.3)
CDKN2A/2B rs10811661 T/C C = 0.18 1.26 DIAGRAM 202 (68.0) 84 (28.3) 11 (03.7)
CDKAL1 rs7754840 C/G C = 0.35 1.25 DIAGRAM 33 (11.1) 139 (46.8) 125 (42.1)
PPARG rs1801282 C/G G = 0.10 1.18 DIAGRAM 241 (81.1) 52 (17.5) 4 (1.4)
HHEX rs1111875 C/T T = 0.37 1.17 DIAGRAM 113 (38.1) 146 (49.2) 38 (12.8)
IGF2BP2 rs1470579 C/A C = 0.34 1.17 DIAGRAM 36 (12.1) 129 (43.4) 132 (44.4)
KCNJ11 rs5219 T/C T = 0.40 1.16 DIAGRAM 37 (12.5) 162 (54.6) 98 (33.0)
SLC30A8 rs13266634 C/T T = 0.25 1.15 DIAGRAM 166 (55.9) 112 (37.7) 19 (6.4)
THADA rs7578597 A/G G = 0.13 1.15 DIAGRAM 241 (81.1) 51 (17.2) 5 (1.7)
CENTD2 rs1552224 A/C C = 0.13 1.14 DIAGRAM+ 226 (76.1) 65 (21.9) 6 (2.0)
NOTCH2 rs10923931 T/G T = 0.11 1.13 DIAGRAM 5 (1.7) 56 (18.9) 236 (79.5)
ADCY5 rs11708067 A/G G = 0.17 1.12 MAGIC 207 (69.7) 80 (26.9) 10 (3.4)
WFS1 rs10010131 G/A A = 0.43 1.11 DIAGRAM 103 (34.7) 131 (44.1) 63 (21.2)
CDC123 rs4747969 C/T C = 0.19 1.11 DIAGRAM 9 (3.0) 97 (32.7) 191 (64.3)
IRS1 rs7578326 A/G G = 0.36 1.11 DIAGRAM+ 123 (41.4) 137 (46.1) 37 (12.5)
CHCHD9 rs13292136 C/T T = 0.06 1.11 DIAGRAM+ 262 (88.2) 32 (10.8) 3 (1.0)
JAZF1 rs864745 G/A A = 0.46 1.10 DIAGRAM 80 (26.9) 151 (50.8) 66 (22.2)
HNF1B rs757210 T/C T = 0.42 1.10 DIAGRAM 59 (19.9) 131 (44.1) 107 (36.0)
HMGA2 rs1531343 C/G C = 0.10 1.10 DIAGRAM+ 2 (0.7) 53 (17.9) 242 (81.5)
ADAMTS9 rs4607103 C/T T = 0.26 1.09 DIAGRAM 161 (54.2) 118 (39.7) 18 (6.1)
TSPAN8 rs7961581 C/T C = 0.29 1.09 DIAGRAM 26 (8.8) 119 (40.1) 152 (51.2)
MTNR1B rs10830963 G/C G = 0.32 1.09 MAGIC 36 (12.1) 119 (40.1) 142 (47.8)
BCL11A rs243021 A/G A = 0.44 1.08 DIAGRAM+ 58 (19.5) 146 (49.2) 93 (31.3)
SLC22A18AS rs231362 G/A A = 0.43 1.08 DIAGRAM+ 93 (31.3) 152 (51.2) 52 (17.5)
ZBED3-AS1 rs4457053 G/A G = 0.35 1.08 DIAGRAM+ 32 (10.8) 142 (47.8) 123 (41.4)
PROX1 rs340874 C/T T = 0.42 1.07 MAGIC 104 (35.0) 134 (45.1) 59 (19.9)
GCK rs917793 T/A T = 0.23 1.07 MAGIC 18 (6.1) 103 (34.7) 176 (59.3)
TSGA13 rs972283 G/A A = 0.44 1.07 DIAGRAM+ 100 (33.8) 132 (44.6) 64 (21.6)
VPS33B rs8042680 A/C A = 0.39 1.07 DIAGRAM+ 52 (17.5) 129 (43.4) 116 (39.1)
HNF1A rs7957197 T/A A = 0.15 1.07 DIAGRAM+ 213 (71.7) 80 (26.9) 4 (1.4)
DGKB rs2191349 T/G G = 0.44 1.06 MAGIC 94 (31.7) 146 (49.2) 57 (19.2)
GCKR rs780094 C/T T = 0.38 1.06 MAGIC 114 (38.4) 143 (48.2) 40 (13.5)
PLEKHF2 rs896854 T/C C = 0.49 1.06 DIAGRAM+ 75 (25.3) 154 (51.9) 68 (22.9)
BCL2A1 rs11634397 G/A A = 0.33 1.06 DIAGRAM+ 138 (46.5) 121 (40.7) 38 (12.8)
KCNQ1 rs2237895 C/A C = 0.42 1.24 Danish population 48 (16.2) 151 (50.8) 98 (33.0)
TCF7L2 rs12255372 T/G T = 0.36 1.43 Wang et al. (2013) 33 (11.1) 149 (50.2) 115 (38.7)

DIAGRAM, diabetes genetics replication and meta-analysis; MAGIC, meta-analysis of glucose and insulin-related traits consortium.
*MAF: minor allele frequency, derived from the ALLELE procedure in SAS GENETICS 9.3.
**Odds ratio reported in previous literature (column Study).

ª 2014 Royal College of Obstetricians and Gynaecologists 413

 Cormier et al.
TaqMan Genotyping Master Mix with a gene-specific pri-
mer and with probe mixture (pre-developed TaqMan SNP
Genotyping Assays; Life Technologies Corporation) in a
final volume of 10 ll. Genotypes were determined using a
StepOnePlus Real-Time PCR System, and analysed using
STEPONE 2.1 (Life Technologies Corporation). To assess accu-
racy, we duplicated the genotyping of all SNPs for 5% of
the study participants.
GRS for predictive modelling of GDM risk
Using 36 SNPs previously associated with T2D,11,16 we con-
structed a simple-count GRS ranging from 0 to 72, where
each individual was scored on the basis of their genotype.
Carriers of the risk allele could get a score of ‘1’ if they
were heterozygotes (carriers of only one risk allele for a
specific SNP) or a score of ‘2’ if they were homozygotes
(carriers of two risk alleles for a specific SNP) for the risk
allele. We then created a weighted GRS per participant by
multiplying the number of risk alleles present per SNP by
the b-estimate reported for this SNP in the meta-analysis
of glucose and insulin-related traits consortium (MAGIC)
and diabetes genetics replication and meta-analysis
(DIAGRAM+) studies,30–32 and from two other
meta-analyses.33,34 Then, to make the GRS more specific to
our population, we used the new explained-variance GRS
model proposed by Che et al.35 to account for the minor
allele frequency of each SNP: explained-variance GRS =
log10(Odds ratio)√[2Minor Allele Frequency(1 Minor
Allele Frequency)]. In the case where the minor allele was
not the allele associated with T2D risk, we considered the
frequency of the risk allele as the substitute in the
explained-variance GRS formula. Then, we summed the
results over the 36 SNPs. The b-estimates are the natural
log of the odds ratios listed in Table 1, and the minor allele
frequencies were derived from the ALLELE procedure in
SAS GENETICS 9.3 (SAS Institute Inc., Cary, NC, USA).
Statistical analyses
Analyses were conducted with SAS 9.2 (SAS Institute Inc.).
Comparisons were performed through the General Linear
Model procedure and using the type-III sum of squares
(for unbalanced study design). Means and standard devia-
tions (SDs) were computed for participants’ characteristics,
anthropometric, and metabolic variables (Table 2). Contin-
uous variables were tested for normality of distribution,
and log transformations of skewed variables were used in
subsequent analyses, where necessary. All genotype distribu-
tions were tested for any deviation from Hardy–Weinberg
equilibrium using the ALLELE procedure in SAS GENETICS 9.3
(SAS Institute Inc.). Significance testing for linkage disequi-
librium coefficient D was obtained using a chi-square test,
likelihood ratio, and Fisher exact test (P ≤ 0.01). Receiver
operating characteristics (ROC) curves were developed to
414
evaluate the ability of each index to predict pre-diabetes
and T2D states. Statistical significance was established at
P ≤ 0.05.
Results
The clinical, anthropometric, and metabolic characteristics
of the study participants are shown in Table 2. There were
no statistical differences between women with prior GDM
and the control group when comparing age, parity, and
time to follow-up after delivery. Weight, BMI, and waist
circumference were higher in women with prior GDM than
in women of the control group (P ≤ 0.02 for all). Fasting
plasma glucose, 2-hour plasma glucose, fasting insulin, area
under the curve for glucose, HOMA-IS, and A1C levels
were significantly higher in women with prior GDM com-
pared with the control group (P ≤ 0.03 for all). Insulin
secretion and insulinogenic indices were lower in women
with prior GDM (P ≤ 0.0001 for all), compared with
women from the control group. The area under the curve
for insulin and 2-hour post-OGTT insulin level did not
statistically differ among groups. A total of 19.6% of
women with prior GDM were diagnosed with impaired
fasting glucose, 36.9% with impaired glucose tolerance, and
18.7% were diagnosed with T2D, compared with 1.2, 12.2,
and 1.2%, respectively, in the control group. Thus, among
GDM women, 63.1% were identified as pre-diabetic 3 years
after delivery.
All SNPs were in Hardy–Weinberg equilibrium. As
shown in Table 3, the GRSs were higher in women with
prior GDM compared with women from the control
group (P < 0.0001 for all). The associations remained sig-
nificant after further adjustments for age, BMI, parity,
oral hypoglycaemic agents and ethnicity (data not shown).
As for the simple-count GRS, women with prior GDM
had an average of 38.6  3.9 risk alleles, whereas the con-
trol groups were carriers of 37.3  3.2 risk alleles
(P < 0.0001).
Given that women with prior GDM had a higher
T2D-associated GRS, we tested whether this GRS was also
predictive of pre-diabetes or T2D in women with prior
GDM. In a general linear model, the explained-variance
GRS significantly differed between pre-diabetic women
and women with prior GDM who remained normogluco-
tolerant at testing (1.20  0.18 versus 1.17  0.17, respec-
tively, P < 0.0001). The ROC curves (Figure 1) evaluated
the discriminative power of the explained-variance GRS
alone, and of age and BMI, or the additive effects of the
three parameters together, between pre-diabetic women
and normoglucotolerant women. The explained-variance
GRS ROC curve had an area under the curve of 0.6122,
whereas the age and BMI ROC curve had an area under
the curve of 0.6269. When adding the explained-variance
ª 2014 Royal College of Obstetricians and Gynaecologists
 Genetic risk score in GDM and T2D

Table 2. Participants’ characteristics, and anthropometric and metabolic variables (n = 296)

GDM Controls P
n = 214 n = 82

Mean  SD or 95% CI Mean  SD or 95% CI

n (%) n (%)

Characteristics*
Age, years 36.4  4.9 35.7–37.0 35.6  5.2 34.5–36.8 0.26
Parity 2.1  0.8 2.0–2.2 2.2  1.0 2.0–2.4 0.34
Time between index pregnancy 3.52  1.97 3.25–3.79 3.82  2.27 3.33–4.31 0.26
and metabolic testing, years
White 189 (93.6%) – 76 (97.4%) – –
Impaired fasting glucose 42 (19.63) – 1 (1.22) – –
Impaired glucose tolerance 79 (36.92) – 10 (12.2) – –
Pre-diabetes, including 135 (63.08) – 12 (14.63) – –
type 2 diabetes
Type 2 diabetes 40 (18.69) – 1 (1.22) – –
Normoglucotolerant 79 (36.92) – 70 (85.37) – –
Oral hypoglycaemic agents 7 (3.27) – 0 (0.0) – –
Insulin 0 (0.0) – 0 (0.0) – –
Anthropometric indicators**
Weight, kg 73.4  17.5 71.1–75.8 68.7  13.9 65.7–71.7 0.02
BMI, kg/m2*** 27.7  6.5 26.8–28.5 25.6  4.9 24.5–26.6 0.007
Waist circumference, cm 91.1  14.6 89.1–93.0 85.6  11.9 83.1–88.2 0.003
Metabolic outcomes**
Fasting plasma 5.92  1.09 5.78–6.07 5.32  0.38 5.24–5.40 <0.0001
glucose, mmol/l***
2-hour post-OGTT 8.33  2.83 7.95–8.71 6.00  1.61 5.65–6.35 <0.0001
glucose, mmol/l***
Fasting insulin, qmol/l 83.54  46.82 77.24–89.85 95.95  39.40 87.42–104.48 0.0003
2-hour post-OGTT insulin, qmol/l 613.07  424.54 555.65–670.49 488.22  346.88 413.14–563.30 0.07
Area under the curve for glucose, 1063.61  269.66 1027.40–1099.82 795.02  162.55 759.62–830.42 <0.0001
mmol/l per minute***
Area under the curve for insulin, 60 726.07  32 538.66 2245.38–56 325.13 58 667.04  30 843.47 51 950.02–65 384.06 0.97
qmol/l per minute
HOMA-IS index*** 0.61  2.17 0.32–0.90 0.54  1.54 0.21–0.87 0.03
Insulin secretion 58.85  31.00 54.66–63.04 73.36  33.20 66.13–80.60 0.0001
Insulinogenic index*** 135.83  121.62 119.46–152.21 319.01  793.52 146.20–491.82 <0.0001
A1C (%) 5.59  3.87 5.54–5.65 5.34  1.98 5.29–5.38 <0.0001

P values derived from a general linear model adjusted for age, parity, oral hypoglycaemic agents, ethnicity, and BMI.
*P values derived from a general linear model.
**P values derived from a general linear model adjusted for age, parity, oral hypoglycaemic agents, and ethnicity.
***Data were log10 transformed.

GRS into the logistic regression, we obtained an area
under the curve of 0.6672, thus improving the predictive
value.
Using the same statistical model as previously described,
we tested the difference in the GRS between women with
prior GDM who remained normoglucotolerant at testing
and women with T2D. All GRSs significantly differed
between groups (P < 0.0001 for all), as shown in Table 4.
ROC curves were plotted using specificity and sensitivity
data from a logistic regression, including the effects of age
and BMI (area under the curve = 0.6761), explained-vari-
ance GRS (area under the curve = 0.5478), and the additive
effects of age, BMI, and explained-variance GRS (area
under the curve = 0.6772), as shown in Figure 2.
Discussion
Main findings
According to the present study, a new genetic score includ-
ing 36 SNPs previously associated with T2D was found to
be associated with GDM. This study also provides evidence
that this genetic score was predictive of pre-diabetes and

ª 2014 Royal College of Obstetricians and Gynaecologists 415

 Cormier et al.
Table 3. Differences in GRS between women with prior GDM and controls (n = 296)
Prior GDM (mean  SD)
n = 214
Simple-count GRS 38.6  3.9
Weighted GRS 2.01  0.27
Explained-variance GRS 1.21  0.18
Figure 1. ROC curves: pre-diabetic (n = 135) versus normoglucotolerant
(n = 79) women.
T2D among women with prior GDM years after delivery.
To our knowledge, this is the first study to show that
combining genetic information within a score generates a
predictor of both GDM and the progression to pre-diabetes
and T2D among women with prior GDM.
Strengths and limitations
The strengths of this study include the use of the new
explained-variance GRS model, because this new weighted
method incorporates odds ratios from meta-analyses and
the risk allele frequencies. Within the same odds ratio, dis-
ease risk will vary depending on the risk allele frequencies.
It has been shown that when the sample size is small, the
explained-variance GRS consistently yielded better perfor-
mance than the weighted GRS.35 In the present study, we
used both approaches (explained-variance GRS and
weighted GRS) and observed similar results. In addition,
the SNPs that were studied were identified from large
meta-analyses and recent GWAS.12,14 Moreover, the use of
an OGTT to assess glucose and insulin responses is more
sensitive for the detection of impaired glucose tolerance,
pre-diabetes, and T2D.24 Confounding factors such as age,
time since the last pregnancy, and BMI were also considered
in the present study. Additional adjustments for oral
416
95% CI Controls (mean  SD) 95% CI P
n = 82
38.1–39.1 37.4  3.2 36.7–38.1 <0.0001
1.98–2.05 1.96  0.22 1.91–2.00 <0.0001
1.18–1.23 1.17  0.15 1.13–1.20 <0.0001
hypoglycaemic agents and ethnicity did not alter the results.
Some limitations for this study should be acknowledged.
Metabolic testing before pregnancy would have been inter-
esting, as pre-pregnancy obesity and abnormal glucose
levels are believed to be strong predictors of T2D. Also,
adding more SNPs to the model, and not only SNPs that
predict T2D, but others that prevent individuals developing
T2D, may show better results as the new explained-variance
GRS takes into account the minor allele frequency and the
b-estimate from odds ratios.
Interpretation
Several studies have already reported associations between
several SNPs and GDM. Huopio et al.36 showed that
rs10830963 of MTNR1B was significantly associated with
GDM, fasting glucose levels, and reduced insulin secretion.
Stuebe et al.10 showed that GDM was associated with SNPs
within TCF7L2 (rs7901695), MTNR1B (rs10830963), and
GCK (rs780094), which are associated with T2D and fasting
glucose levels in non-pregnant women. In addition, a higher
number of risk alleles in women with a history of GDM was
also reported by Lauenborg et al.,37 where they observed
associations in 11 SPNs, recently associated with T2D, with
GDM, and demonstrated the combined additive effect of all
T2D susceptibility alleles on the predictive risk of GDM,
and performed ROC curves to assess the discriminative
accuracy of these genetic variants in GDM. They showed
that T2D risk alleles additively increase the risk of GDM.
The discriminative accuracy of genetic variants associated
with T2D and GDM can be assessed looking at the area
under the curves evaluated by ROC curves. The ROC curves
were elaborated for the prediction of T2D risk based on 36
SNPs (included in a GRS), clinical characteristics (age and
BMI), and both. Interestingly, the area under the curve of
age and BMI was a stronger predictor of T2D risk when the
explained-variance GRS was considered, suggesting that
genetic variants included in the explained-variance GRS
added to known predictive factors of T2D risk (Figures 1
and 2). In comparison, a recent GWAS has shown ROC
curves with an area under the curve of 0.66 (95% CI 0.63–
0.68) for the predictive modelling of T2D based on SNPs and
clinical characteristics combined (age, sex, and BMI).38 Pre-
vious studies have reported the area under the curves for
ª 2014 Royal College of Obstetricians and Gynaecologists

Table 4. Differences in GRS between normoglucotolerant and T2D status among women with prior GDM (n = 119)
Normoglucotolerant (mean  SD)
n = 79
Simple-count GRS 38.1  4.0
Weighted GRS 1.95  0.25
Explained-variance GRS 1.17  0.17
Figure 2. ROC curves: normoglucotolerant (n = 79) versus type 2
diabetic (n = 40) women.
genetic information, age, and BMI, and obtained a large
range of results (0.73, 0.86, and 0.58), depending on the
number of gene variants tested.37,39,40 Differences between
results from the present study and prior studies looking at
genetic discrimination for T2D can be explained by the fact
that in our study, ROC curves were evaluated only in women
with prior GDM (GDM versus controls in the other studies),
and therefore women were already more likely to develop
T2D because of their history of GDM. Nevertheless, we
observed that the GRS predicts progression to pre-diabetes
and T2D, even in this high-risk population.
The effect sizes of common variants influencing T2D risk
are low, and genetic predispositions may explain approxi-
mately 5–10% of the variance;41 however, the estimated
effect-size distribution suggested the existence of increas-
ingly large numbers of susceptibility SNPs with decreasingly
small effects.42 SNPs with intermediate minor allele fre-
quency (5–20%) contained an unusually small number of
susceptibility loci and explained a relatively small fraction
of heritability compared with what would be expected from
the distribution.43 For these reasons, the explained-variance
GRS was elaborated by weighting each risk allele by its
respective effect size on T2D risk and its minor allele fre-
quency. In the present study, the explained-variance GRS
ª 2014 Royal College of Obstetricians and Gynaecologists
Genetic risk score in GDM and T2D
95% CI T2D (mean  SD) 95% CI P
n = 40
37.2–39.0 38.7  4.5 37.3–40.1 <0.0001
1.90–2.01 2.00  0.28 1.91–2.09 <0.0001
1.13–1.20 1.20  0.18 1.14–1.25 <0.0001
indicated a genetic difference between GDM women and
the control group, and also between pre-diabetic (including
T2D) women and women with prior GDM who remained
normoglucotolerant after testing. This finding is consistent
with previous studies reporting that a combination of all
risk alleles into a weighted GRS was significantly associated
with the risk of T2D.16 A higher GRS is also associated
with less probability of returning to a normoglucotolerant
state, and with an increased risk of developing T2D.16
Consistent with the literature, results of anthropometric
measurements and glucose homeostasis clearly demon-
strated metabolic deteriorations in women with prior
GDM, compared with women without GDM.2,5 In the
present study, women with prior GDM were overweight,
had higher glycaemic traits, and had decreased insulin sen-
sitivity. Pre-diabetes and T2D were more prevalent in
women with prior GDM compared with women from the
control group. Similarly, in Polish women with GDM, the
cumulative incidence of impaired glucose tolerance and
T2D over a 3-year follow-up was 41.5%.44 Hunger-Dathe
et al.45 showed that the prevalence of impaired glucose tol-
erance was higher for pre-diabetes (28–53%) and for T2D
(11–43%) in a longer follow-up after GDM (up to
3–15 years). By taking into account the new 2013 guide-
lines from the Canadian Diabetes Association,20 more
women were actually at risk because of lower cut-off val-
ues. In 2009, a meta-analysis with 675 455 women and
10 859 T2D cases demonstrated that women with GDM
had a nearly 7.5-fold increased risk of predicted T2D.5 Kim
et al.6 reported in a systematic review that more than 70%
of women with GDM will eventually progress to T2D. The
identification of factors associated with subsequent T2D
development in women with GDM may determine subjects
at risk, in which case more aggressive preventive care could
be provided to prevent the development of pre-diabetes
and T2D. Indeed, lifestyle intervention has been shown to
attenuate the genetic contribution to T2D risk.16,46
Conclusion
In conclusion, findings from the present study suggest that
a genetic score is associated with both GDM and progres-
sion to pre-diabetes and T2D in women with prior GDM.
417
 Cormier et al.
In addition, we observed that including a genetic score and
traditional risk factors for T2D, such as age and BMI,
resulted in a greater discrimination of the risk of pre-diabe-
tes in women with prior GDM. This result suggests that
using an explained-variance GRS combined with traditional
risk factors for T2D is likely to be more accurate in pre-
dicting future risk of progression to T2D among women
with prior GDM.
Disclosure of interests
The authors did not declare any conflicts of interest.
Contribution to authorship
HC and JV contributed equally to this work. HC and JV
performed the statistical analyses, interpreted the data, and
wrote the article; JV and VG participated in the recruit-
ment of the women and collected data. JR was the princi-
pal investigator and designed the study, supervised the
research, directed the data analysis and interpretation, and
assisted with the manuscript preparation. SJW, MCV, and
AT assisted with the development of the research study
design and protocol, as well as data analysis and interpreta-
tion. All the authors revised the article.
Details of ethics approval
The data collection scheme and the study protocol were
approved by the Laval University Hospital Research Center
Ethics Committee (ref. no. 129.05.10) on 27 May 2009.
Funding
This work was supported by the Fonds de la recherche du
Quebec en sante (FRQS) and the Canadian Institutes of
Health Research (CIHR) (grant number OOP-98026).
Acknowledgements
We thank all the participants of this study. We would also
like to express our gratitude to Genevieve Faucher and
Ann-Marie Paradis, from Laval University, for their help
with the recruitment of participants and with technical sup-
port. This work is supported by the Canadian Institutes for
Health Research (CIHR) and by the Fonds de la recherche
du Quebec en sante (FRQS). Andre Tchernof is a research
chair in bariatric and metabolic. Marie-Claude Vohl holds a
Tier 1 Canada Research Chair in Genomics Applied to
Nutrition and Health. Julie Robitaille is the recipient of a
Junior Investigator scholarship from the FRQS. &
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