Association of atherogenic index of plasma and its modified indices with gestational diabetes mellitus: a prospective cohort study based on the Korean population

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Background Gestational diabetes mellitus (GDM) is a common pregnancy complication, yet current diagnosis at 24–28 weeks may occur after metabolic changes have already begun. The atherogenic index of plasma (AIP, log₁₀[TG/HDL-C]) has shown promise for early GDM risk stratification, but it does not incorporate obesity-related parameters. We evaluated whether first-trimester AIP and its modified indices, AIP-BMI and AIP-WC, are associated with subsequent GDM and compared their predictive performance. Methods This secondary analysis of a prospective Korean cohort included 581 women with singleton pregnancies. AIP, AIP-BMI (AIP × BMI), and AIP-WC (AIP × waist circumference) were calculated using fasting measurements obtained at 10–14 weeks of gestation; BMI and waist circumference were algebraically reconstructed from the full-precision components of the hepatic steatosis index and fatty liver index because contemporaneous direct measurements were unavailable in the public dataset. GDM was diagnosed at 24–28 weeks using the two-step ACOG approach. Multivariable logistic regression, restricted cubic spline, sensitivity, subgroup, and receiver operating characteristic analyses were performed. Results GDM occurred in 36 women (6.2%). In the fully adjusted model, AIP (per 0.1-unit increase: OR 1.66, 95% CI 1.36–2.03; Q3 vs Q1: OR 7.86, 95% CI 1.93–32.08), AIP-BMI (OR 1.20, 95% CI 1.11–1.31), and AIP-WC (OR 1.05, 95% CI 1.03–1.08) were associated with GDM (all P < 0.001). Overall associations were significant in restricted cubic spline analyses, without evidence of nonlinearity. Among individual indices, AIP-BMI had the largest apparent AUC (83.05%, sensitivity 81%, specificity 80%), followed by AIP-WC (81.32%) and AIP (78.66%). The AIP + AIP-BMI model had the largest apparent AUC among evaluated models (84.19%, sensitivity 81%, specificity 81%). Results remained broadly consistent in sensitivity analyses excluding participants with NAFLD, whereas subgroup analyses were underpowered to detect interactions. Conclusion First-trimester AIP, AIP-BMI, and AIP-WC were associated with subsequent GDM, and AIP-BMI showed higher apparent discrimination than AIP alone in this sample. These findings require confirmation in larger cohorts with directly measured anthropometry and appropriate internal and external validation.