The impact of climate variability on health has become increasingly relevant given the global rise in air temperatures over the past century.1,2 Extreme weather patterns can adversely influence health -directly, as in the case of hyperor hypothermia -and indirectly, by triggering respiratory exacerbations, infectious outbreaks, water-borne diseases and injuries. However, there is also growing evidence supporting a link between air temperature, metabolic function and energy expenditure. Brown adipose tissue aids with acclimatization to cold through its unique ability to generate heat by uncoupling cellular respiration from mitochondrial adenosine triphosphate (ATP) synthesis.4-6 Based on findings from studies involving animals and humans, the effects of brown adipose tissue activation extend beyond thermogenesis, by influencing whole-body metabolism and possibly overall body weight.7-18 Small intervention trials involving humans have suggested that even mild exposure to ambient cold -such as lowering a thermostat from 24°C to 19°C -can increase activity of brown adipose tissue by 30%-40%, resulting in substantial improvements in insulin sensitivity. [15][16][17][18] In theory, greater insulin sensitivity should improve glucose handling, but whole-population studies evaluating the potential for cold exposure to reduce glucose mishandling are lacking.We examined the impact of variation in outdoor air temperature on the risk of gestational diabetes mellitus, a transient form of diabetes arising by midpregnancy. Placental hormones lead to a temporary state of insulin resistance, starting in the second trimester of pregnancy and continuing until delivery.19 Gestational diabetes mellitus arises when the compensatory increase in insulin production fails to maintain normal blood glucose levels. This condition affects more than 15 million pregnancies worldwide each year 20 and can have serious consequences for mother, baby and the delivery process. [21][22][23] Hence, gestational diabetes mellitus offers an opportunity to study the short-term effect of ambient outdoor temperature on human metabolism. ABSTRACT BACKGROUND: Cold-induced thermogenesis is known to improve insulin sensitivity, which may become increasingly relevant in the face of global warming. The aim of this study was to examine the relation between outdoor air temperature and the risk of gestational diabetes mellitus.