Association of Low Fecal Intestinal Alkaline Phosphatase with Gestational Diabetes Mellitus: Evidence from a Cross-Sectional Study

Abstract

Background
Gestational diabetes mellitus (GDM) is a major metabolic complication of pregnancy. Beyond classical mechanisms, emerging evidence suggests that gut-derived metabolic endotoxemia may contribute to dysglycemia. Intestinal alkaline phosphatase (IAP), a key enzyme involved in maintaining gut barrier integrity and detoxifying lipopolysaccharides, has been linked to type 2 diabetes mellitus. However, its role in GDM remains largely unexplored. This study was designed to evaluate fecal IAP levels in pregnant women and examine their association with GDM.

Methods
In this hospital-based cross-sectional analytical study, 198 pregnant women underwent screening for GDM using a 75-g oral glucose tolerance test. Participants were categorized into GDM (n=55) and normal glucose tolerance (NGT, n=143) groups according to the WHO 2013 criteria. Stool samples were collected, and IAP levels were measured using an enzymatic colorimetric assay.

Results
Fecal IAP level was significantly lower in women with GDM than in NGT (median 23.59 vs 46.48 U/gm, p < 0.001). Lower IAP level remained independently associated with GDM after adjustment for body mass index and previous GDM (adjusted OR 0.98 per unit increase; 95% CI 0.97–0.99; p<0.001). A graded relationship was observed between declining IAP level and GDM. ROC analysis demonstrated modest discrimination (AUC 0.676), but a threshold of approximately 65 U/gm yielded high sensitivity (89.1%) with lower specificity.

Conclusion
Reduced fecal IAP is independently associated with GDM and may serve as a complementary biomarker for risk stratification. Prospective studies are warranted to determine its predictive value and explore its potential as a therapeutic target.

Bangladesh J Medicine 2026; Vol. 37, No. 2(1) Supplementation: 208