We applied a Mendelian randomisation (MR) approach using PRS calculated from maternal non-transmitted alleles, to explore the causality of associations between maternal pre-/early-pregnancy BMI and offspring birth weight (BW) and child/adolescent adiposity. For the association between maternal BMI and offspring BW, our MR and confounder adjusted multivariable regression (MV) estimates were similar. In contrast, for offspring adiposity outcomes beyond 1 year of age (including BMI and DXA-determined FMI), the MR estimates were weaker than the MV estimates. These results markedly strengthen the evidence that confounder adjusted observational associations between maternal BMI and offspring adolescent adiposity are subject to residual confounding. We found no strong evidence for a causal effect of maternal BMI on offspring adiposity beyond birth, although based on the present results we cannot rule out a small to moderate causal effect.
Our data build on two previous MR studies which investigated associations between maternal BMI and offspring child/adolescent adiposity [
14,
23], and a methodological paper which presented a limited investigation of adiposity outcomes as an empirical example [
24]. Although the previous studies provided no strong evidence for a causal effect, they were limited by wide confidence intervals and/or potential biases (see the “Strengths and limitations” section). The present study overcame these limitations by using more powerful PRS and a maternal non-transmitted allele score approach. For the association between maternal BMI and offspring BW, our MR and MV estimates were highly concordant, in agreement with previous MR studies that supported a causal effect of greater maternal BMI on greater offspring BW [
26,
27]. We have previously shown that genetic confounding (i.e. confounding due to direct effects of maternal alleles inherited by the offspring) is unlikely to explain the association of maternal BMI with BW, but may potentially be important for the association with adolescent BMI [
40]. The present results are consistent with this, as well as with the balance of evidence from negative paternal exposure control studies [
12‐
18] and within sibship analyses [
19,
20], which suggests that familial confounding is an important explanation of the maternal BMI-offspring child/adolescent adiposity association. Studies that examined the effect of extreme maternal obesity using a pre- and post-bariatric surgery design [
91‐
94] have small sample sizes and have not been entirely consistent, therefore do not provide strong evidence against this conclusion.
Although we found no strong evidence
for a causal effect in late childhood/adolescence, we cannot rule out a small to moderate causal effect, due to the imprecision of our MR estimates. Indeed, the primary lassosum MR estimates were greater than zero for 15-year BMI and 14–18-year FMI. We do not interpret these as unbiased estimates for the causal effect of maternal BMI, because of the possibility of pleiotropic bias (see below). These results do suggest however that some maternal exposure(s) that are correlated with the maternal BMI PRS have a causal effect on offspring child/adolescent adiposity, although our analyses are unable to distinguish whether this is a pre or postnatal effect. Plausible mechanisms include intrauterine effects such as fetal overnutrition [
1] and postnatal effects such as maternal influence on offspring eating behaviour [
95], but other mechanisms have been hypothesised, including periconceptional effects (such as altered oocyte structure or function [
3]). In linear regression analyses, we found moderate to strong evidence for associations between the maternal non-transmitted allele BMI PRS and offspring adolescent adiposity (including BMI and DXA-determined FMI). These observed maternal genetic effects merit further investigation in other datasets, particularly as previous studies have not found evidence for parental genetic effects on BMI in childhood [
96] or adulthood [
97].
In ALSPAC and BiB White Europeans, we observed associations between the maternal BMI PRS and potential confounders, including parental occupation, education, age and maternal smoking. These results invite careful consideration of which of the ever-increasing number of GWS associated BMI SNPs are likely (in combinations) to be the most valid instruments for MR studies, having taken account of all IV assumptions.
Strengths and limitations
Our study has several key strengths. We studied two prospective birth cohorts with maternal and offspring genome-wide genotype data, maternal BMI measurements and offspring adiposity outcomes available, allowing us to conduct mother-offspring MR analyses. We used state-of-the-art methods to calculate a powerful PRS from around 80,000 SNPs. This yielded a substantial increase in statistical power over previous MR studies, which analysed similar ALSPAC datasets to ours, but employed either a single SNP in the
FTO gene [
14] or allele scores calculated from up to 97 SNPs [
23,
24] (similar to the “Speliotes” and “Locke” IVs in the present analysis). Our primary lassosum PRS explained 3–7% of maternal BMI variance, compared to ~ 1.5% for the strongest IVs used previously (power calculations are given in Additional file
1: Supplementary information S34).
Another strength over previous work is our use of maternal non-transmitted allele PRS, thereby avoiding the need to control for genetic inheritance by adjusting for offspring genotype. A previous methodological paper made use of this approach [
24], but conducted a much more limited analysis of a far smaller subset of adiposity outcomes than that which we have explored here. Controlling for offspring genotype may be suboptimal for two distinct reasons: (i) it may introduce collider bias if paternal genotype influences the offspring outcome independently of offspring genotype (i.e. if paternal genetic effects exist) [
24,
35] and (ii) if the investigator adjusts for a
weighted allele score, this may introduce bias by inadequately blocking the genetic inheritance path (Personal communication, Wang G, Warrington N, Evans DM, 2020). Because these two biases may be in opposite directions, the net direction of any bias affecting the largest previous study [
23] is uncertain. We acknowledge that our primary MR estimates may be affected by pleiotropic bias due to the large number of SNPs, many of which had small effect sizes, that we used to calculate the PRS. This possibility is also suggested by the associations that we observed between the lassosum BMI PRS and several potential confounders of the maternal BMI-offspring adiposity association. However, sensitivity analyses suggested that for most outcomes, pleiotropic bias is likely to be away from zero, which would weaken the apparent evidence for an MR-MV difference (Additional file
1: Supplementary information S32, S33). Thus, our primary MR results are conservative, in that they may overstate the size of the causal effect (which we hypothesised to be zero). The fact that for 10-and 15-year BMI, using more SNPs yielded increased precision and stronger evidence for an MR-MV difference (Fig.
2), despite the potential pleiotropic bias away from zero, illustrates the benefit of our approach.
We also conducted extensive sensitivity analyses to explore other potential biases in our results. When we used a linear mixed model (LMM) to adjust for population structure, the results were similar to our primary estimates. We did not remove cryptic relatedness for our primary analyses, in order to maximise the sample size and because the LMM controls for bias due to cryptic relatedness [
71]. However, results were similar when we removed cryptic relatedness at a level corresponding to first cousins. Finally, we found no strong evidence that maternal and paternal lassosum BMI PRS were correlated, suggesting that our results are not importantly biased due to assortative mating.
We acknowledge several limitations of our study. First, although the results in BiB and ALSPAC were similar, replication in other cohorts with suitable data, and in particular with adolescent adiposity measures (which we could only examine in ALSPAC) would be valuable. A previous study meta-analysed data from ALSPAC and the Generation R cohort using 32 maternal SNPs [
23], but we were unable to extend our approach to Generation R due to the unavailability of maternal genome-wide SNP data. Additional file
1: Supplementary information S35 compares the present analysis to previous analyses of ALSPAC data. We have only studied UK participants. However, the similarity of findings between White European and South Asian BiB participants, and between BiB (a cohort with high levels of deprivation born during the obesity epidemic) and ALSPAC (more affluent than the UK average) suggest that our findings may be generalisable to other populations. Second, BMI (especially self-reported BMI) is an imperfect proxy measure for adiposity. However, it has been shown previously in ALSPAC that self-reported pre-pregnancy BMI is strongly correlated with BMI measured in early pregnancy [
23], and that any misreporting does not markedly differ by mean weight [
98]. There is also evidence that the correlation with directly measured adiposity is strong for child and adult BMI [
99,
100] and moderate for neonatal weight [
101]; furthermore, our results were similar for DXA derived FMI. Third, we assumed that causal relationships between exposures and outcomes were linear. Although our data provided no evidence for non-linearity, a slight plateauing of the observational association between maternal BMI and offspring child/adolescent BMI at higher maternal BMI levels was previously observed in a large meta-analysis [
6]. MR estimates such as ours, which assume linearity, nevertheless approximate the population-averaged causal effect (which is the average effect resulting from a unit increase in the exposure for all individuals in the population, regardless of their initial exposure level) [
102]. However, given the shape of the observational association [
6], it is plausible that our MR estimates overstate the true causal effect for mothers with overweight/obesity. Finally, the samples used for some of our analyses (particularly for MV models) were smaller than the full samples at baseline due to missing data and loss to follow-up, raising the possibility that our results are affected by selection bias. However, the distributions of maternal BMI, BW and offspring sex were similar for the samples used for our analyses and the samples at baseline, and MV results were similar when we refitted models on larger samples without excluding individuals with missing paternal BMI data. It therefore seems unlikely that selection bias would be of sufficient magnitude to alter our conclusions.