Population health significance of gestational diabetes

Maternal genotype and gestational diabetes

OBJECTIVE

To determine whether genetic variants associated with glucose homeostasis are associated with gestational diabetes (GDM).

STUDY DESIGN

We genotyped 899 self-identified Caucasian women and 386 self-identified African-American women in the Pregnancy, Infection and Nutrition (PIN) Studies cohorts for 38 single-nucleotide polymorphisms (SNPs) associated with type II diabetes (T2DM) and/or glucose homeostasis in European populations.

RESULTS

GDM was diagnosed in 56 of 899 (6.2%) Caucasian and 24 of 386 (6.2%) African-American women. Among Caucasian women, GDM was associated with carriage of TCF7L2 rs7901695, MTNR1B rs10830963 and GCKR rs780094 alleles that are associated with T2DM and fasting glucose in nonpregnant populations. Among African-American participants, we found an increased risk among TSPAN8 rs7961581 C allele homozygotes and reduced risk among carriers of the JAZF1 rs864745 T allele.

CONCLUSION

We found several SNPs that are associated with GDM risk in the PIN cohorts. Maternal genotyping may identify women at risk for impaired gestational glucose tolerance.

Socio-demographic Risk Factors of Gestational Diabetes Mellitus

OBJECTIVE

The objective of the study was to report the socio demographic risk factors of gestational diabetes mellitus (GDM).

METHODS

This study was conducted in the Institute of Chemical Sciences, University of Peshawar. In this study 103 GDM and 97 healthy pregnant women (HPW) were registered in Khyber Teaching Hospital (KTH), Peshawar, Pakistan. Women with gestational diabetes were diagnosed with 75mg Oral Glucose Tolerance Test (OGTT). Data was collected through questionnaire which had information about sociodemographic risk factors.

RESULTS

Maternal age, BMI and parity of GDM were significantly higher at P<0.05 as compared to HPW. Previous history of gestational diabetes and family history of diabetes of GDM women were also significantly higher at P<0.001 as compared the control group. Socioecnomic status, education level and occupations of GDM and HPW were not significantly different.

CONCLUSION

Maternal age, BMI, parity, previous history of gestational diabetes and family history of diabetes are the high risk factors of GDM. Socioecnomic status does not affect the prevalence of GDM.

Advancements and challenges in generating accurate animal models of gestational diabetes mellitus

The maintenance of glucose homeostasis during pregnancy is critical to the health and well-being of both the mother and the developing fetus. Strikingly, approximately 7% of human pregnancies are characterized by insufficient insulin production or signaling, resulting in gestational diabetes mellitus (GDM). In addition to the acute health concerns of hyperglycemia, women diagnosed with GDM during pregnancy have an increased incidence of complications during pregnancy as well as an increased risk of developing type 2 diabetes (T2D) later in life. Furthermore, children born to mothers diagnosed with GDM have increased incidence of perinatal complications, including hypoglycemia, respiratory distress syndrome, and macrosomia, as well as an increased risk of being obese or developing T2D as adults. No single environmental or genetic factor is solely responsible for the disease; instead, a variety of risk factors, including weight, ethnicity, genetics, and family history, contribute to the likelihood of developing GDM, making the generation of animal models that fully recapitulate the disease difficult. Here, we discuss and critique the various animal models that have been generated to better understand the etiology of diabetes during pregnancy and its physiological impacts on both the mother and the fetus. Strategies utilized are diverse in nature and include the use of surgical manipulation, pharmacological treatment, nutritional manipulation, and genetic approaches in a variety of animal models. Continued development of animal models of GDM is essential for understanding the consequences of this disease as well as providing insights into potential treatments and preventative measures.

Pre-pregnancy overweight overtakes gestational diabetes as a risk factor for subsequent metabolic syndrome

OBJECTIVE

Gestational diabetes mellitus (GDM) is associated with an increased risk of subsequent diabetes and metabolic syndrome (MS). The independent significance of overweight, often associated with GDM, is controversial. This study was aimed to investigate the prevalence of MS and carotid intima-media thickness (CIMT) values in normal and overweight women with previous insulin-treated GDM and control without GDM 19 years after the index pregnancy.

METHODS

The study group consisted of 61 women with prior GDM and 55 controls who gave birth in Oulu University Hospital between 1988 and 1993. These women were further divided into subgroups according to pre-pregnancy BMI (<25 or ≥25 kg/m(2)). In 2008-2010, anthropometrics and blood pressure were measured, blood samples were taken, and an oral glucose tolerance test was performed to investigate the components of MS. CIMT was measured by Doppler ultrasound.

RESULTS

Total prevalence of MS was 62% in the GDM group and 31% in the control group (P=0.001); it was highest (86%) in GDM women with pre-pregnancy overweight. CIMT was significantly thicker (0.67 vs 0.56 mm, P=0.007) and more often abnormal (71.7 vs 45.3%, P=0.004) in the GDM group compared with the controls. In logistic regression analysis, the strongest factor predicting MS in the whole study population was pre-pregnancy overweight.

CONCLUSIONS

Pre-pregnancy overweight was the strongest predictive factor for later MS, whereas GDM indicated increased risk of subsequent diabetes and subclinical atherosclerosis. The risk of MS was highest when both of these factors were present.

Preventing type 2 diabetes after gestational diabetes: women's experiences and implications for diabetes prevention interventions

AIMS

To explore factors influencing post-natal health behaviours following the experience of gestational diabetes, and to elicit women's views about the feasibility of lifestyle intervention to prevent diabetes during the first 2 years after childbirth.

METHODS

Qualitative study using semi-structured interviews with women who had gestational diabetes. In phase 1 (31 women), interviews explored the experience of gestational diabetes, ideas about future risk of diabetes and factors influencing post-natal health-related behaviours. Statements were developed summarizing women's views of lifestyle change to prevent diabetes. In phase 2 (14 women), interviews explored how the passage of time had contributed to changes in health behaviour, and the statements were used to develop views about diabetes interventions.

RESULTS

Women were aware of their risk of developing diabetes, but did not always act on such knowledge. Pregnancy motivated behaviour changes to benefit the unborn child, but after delivery these changes were often not maintained. Tiredness, maternal attachment and childcare demands were prominent barriers in the early post-natal months. Later, work, family and child development became more significant barriers. Many women became more receptive to healthy eating messages around the time of weaning. Women were positive about long-term support for self-management to reduce their diabetes risk.

CONCLUSIONS

There is potential to reduce the risk of Type 2 diabetes post-natally among women with gestational diabetes. Interventions need to be developed that take into account contextual factors and competing demands, are flexible and respond to women's individual circumstances. Randomized trials of such interventions are warranted.

Lifestyle modifications in the development of diabetes mellitus and metabolic syndrome in Chinese women who had gestational diabetes mellitus: a randomized interventional trial

OBJECTIVES

To study whether lifestyle intervention can reduce the development of type II diabetes mellitus (DM) and metabolic syndrome (MS) among Chinese women who had gestational diabetes mellitus (GDM).

METHODS

A prospective randomized controlled interventional trial of 450 women who had GDM and impaired glucose tolerance (IGT) postpartum. Advice on diet and exercise was given to the intervention group and reinforced in each follow-up visit. Women in both arms were followed for 36 months. Blood pressure and anthropometry were measured at each visit and blood tests were repeated.

RESULTS

Fewer women in the intervention group developed DM (15 versus 19 %) but this was not statistically significant, and there was a lower incidence of DM among women over 40 years old. No difference was found in fasting glucose, insulin and homeostasis model assessment (HOMA) index. Both systolic and diastolic blood pressures, and triglyceride level, were lower but the significance was inconsistent among visits. BMI and percentage body fat were also significantly lower in the later visits. There was no difference in waist-hip ratio and basal metabolic rate.

CONCLUSIONS

Our results demonstrate a trend towards lower incidence of type II DM within 3 years postpartum in GDM women given lifestyle advice, which also potentially offers protection against development of MS, in terms of lower blood pressure and triglyceride level. Women over 40 years old are more likely to benefit. Future studies should address ways to maximize compliance to lifestyle intervention as its potential benefits can be undermined by challenges of motherhood.

DALI: Vitamin D and lifestyle intervention for gestational diabetes mellitus (GDM) prevention: an European multicentre, randomised trial - study protocol

Background

Gestational diabetes mellitus (GDM) is an increasing problem world-wide. Lifestyle interventions and/or vitamin D supplementation might help prevent GDM in some women.

Methods/design

Pregnant women at risk of GDM (BMI≥29 (kg/m²)) from 9 European countries will be invited to participate and consent obtained before 19+6 weeks of gestation. After giving informed consent, women without GDM will be included (based on IADPSG criteria: fasting glucose<5.1mmol; 1 hour glucose <10.0 mmol; 2 hour glucose <8.5 mmol) and randomized to one of the 8 intervention arms using a 2×(2×2) factorial design: (1) healthy eating (HE), 2) physical activity (PA), 3) HE+PA, 4) control, 5) HE+PA+vitamin D, 6) HE+PA+placebo, 7) vitamin D alone, 8) placebo alone), pre-stratified for each site. In total, 880 women will be included with 110 women allocated to each arm. Between entry and 35 weeks of gestation, women allocated to a lifestyle intervention will receive 5 face-to-face, and 4 telephone coaching sessions, based on the principles of motivational interviewing. The lifestyle intervention includes a discussion about the risks of GDM, a weight gain target <5kg and either 7 healthy eating ‘messages’ and/or 5 physical activity ‘messages’ depending on randomization. Fidelity is monitored by the use of a personal digital assistance (PDA) system. Participants randomized to the vitamin D intervention receive either 1600 IU vitamin D or placebo for daily intake until delivery. Data is collected at baseline measurement, at 24–28 weeks, 35–37 weeks of gestation and after delivery. Primary outcome measures are gestational weight gain, fasting glucose and insulin sensitivity, with a range of obstetric secondary outcome measures including birth weight.

Discussion

DALI is a unique Europe-wide randomised controlled trial, which will gain insight into preventive measures against the development of GDM in overweight and obese women.

Trial registration

ISRCTN70595832

Impact of health beliefs, social support and self-efficacy on physical activity and dietary habits during the post-partum period after gestational diabetes mellitus: study protocol

Background

Gestational diabetes mellitus (GDM) is defined as a glucose intolerance of variable severity occurring or diagnosed for the first time during pregnancy. Numerous epidemiological studies show that this disorder affects between 1 and 18% of pregnancies, depending on the ethnicity of the populations studied, the diagnostic criteria, or the body mass index (BMI). Its incidence is constantly rising worldwide. Patients with GDM have a high risk of developing type 2 diabetes in the months after delivery. For this reason, GDM patients are encouraged to practice specific health behaviors (dietary habits, physical activity) during the postpartum period. It is important to identify the factors that may impact adherence to these behaviors.

Methods/Design

A targeted sample size of 200 eligible pregnant women with a diagnosis of GDM will be enrolled in this prospective, cohort study. They will be recruited from 30-36 weeks of gestation as part of their diabetes consultation in Geneva University Hospital (GUH) maternity unit. Psychosocial variables that could impact adherence to health behaviors in the postpartum period (behavioral intentions, risk perceptions, general knowledge about diabetes, health beliefs, social support, self-efficacy) will be evaluated using specific tools at the end of pregnancy, at 6 weeks postpartum and at 6 months postpartum. Multiple regression analyses will be performed on SPSS.

Discussion

For the first time in Europe, the objective of this research is to study in women with very recent GDM the link between dietary habits, physical activity levels, and psychosocial and cognitive factors possibly involved in the adoption of health behaviors in the postpartum period. These factors have been identified in the literature, but to date have never been combined in a single study. The study will allow a predictive theoretical model of health behavior to be established and used as a basis for reflection to optimize interventions carried out on women who have had GDM.

Healthful dietary patterns and type 2 diabetes mellitus risk among women with a history of gestational diabetes mellitus

BACKGROUND

Type 2 diabetes mellitus (T2DM) has reached epidemic proportions. Women with gestational diabetes mellitus (GDM) are at high risk for T2DM after pregnancy. Adherence to healthful dietary patterns has been inversely associated with T2DM in the general population; however, whether these dietary patterns are associated with progression to T2DM among a susceptible population is unknown.

METHODS

Four thousand four hundred thirteen participants from the Nurses' Health Study II cohort with prior GDM were followed up from 1991 to 2005. We derived the alternate Mediterranean diet (aMED), Dietary Approaches to Stop Hypertension (DASH), and alternate Healthy Eating Index (aHEI) dietary pattern adherence scores from a post-GDM validated food-frequency questionnaire, with cumulative average updating every 4 years. Multivariable Cox proportional hazards models estimated the relative risk (hazard ratios) and 95% confidence intervals.

RESULTS

We observed 491 cases of incident T2DM during 52 743 person-years. All 3 patterns were inversely associated with T2DM risk with adjustment for age, total calorie intake, age at first birth, parity, ethnicity, parental diabetes, oral contraceptive use, menopause, and smoking. When we compared participants with the highest adherence (quartile 4) vs lowest (quartile 1), the aMED pattern was associated with 40% lower risk of T2DM (hazard ratio, 0.60 [95% CI, 0.44-0.82; P=.002]); the DASH pattern, with 46% lower risk (0.54 [0.39-0.73; P.001]); and the aHEI pattern, with 57% lower risk (0.43 [0.31-0.59; P.001]). Adjustment for body mass index moderately attenuated these findings.

CONCLUSIONS

Adherence to healthful dietary patterns is associated with lower T2DM risk among women with a history of GDM. The inverse associations are partly mediated by body mass index.

The association between serum asymmetric dimethyl arginine levels and a history of gestational diabetes among healthy women

In recent years, asymmetric dimethyl arginine (ADMA) has emerged as an early marker and/or mediator of endothelial dysfunction and it has been proved to be a novel, independent risk factor of cardiovascular and metabolic diseases. Our aim in this study was to compare the ADMA concentrations among patients with a history of gestational diabetes mellitus (GDM) with controls. Thirty women with a history of GDM and 40 age-matched and BMI-matched healthy controls were enrolled in this study. ADMA concentrations, fasting blood glucose levels, 75-g oral glucose tolerance test (OGTT) second hour plasma glucose levels, and insulin levels were compared between two groups. The fasting blood glucose levels were also significantly higher in patients with GDM history. Although second hour values of 75-g OGTT were higher in patients with GDM history, the difference between groups was not statistically significant. However, the insulin and homeostatic model assessment insulin resistance levels were statistically significantly higher in patients with a history of GDM. The concentrations of ADMA were found to be statistically higher in patients with a history of GDM (0.45 ± 0.11 vs. 0.31 ± 0.13 μmol/l, respectively; P = 0.01). This study shows that women who had a history of GDM are under risk for cardiovascular diseases, although they seem to be healthy and have normal blood biochemical levels, because of elevated serum ADMA levels. Clinicians should be aware of this increased cardiovascular disease risk among patients with a history of GDM.

Gestational diabetes mellitus among women born in South East Asia: a review of the evidence

OBJECTIVE

The aim of this paper was to examine rates of gestational diabetes mellitus (GDM) among women born in South East Asia, now residing in a developed country

DATA SOURCES

Established health databases including: SCOPUS, MEDLINE, CINAHL, EMBASE and Maternity and Infant Care were searched for journal papers, published 2001-2011.

STUDY SELECTION

Studies that examined GDM among women born in South East Asia (SEA) were sought. Keywords included gestational diabetes and a search term for Asian ethnicity (Asian, Asia, race, ethnic, and ethnicity). Further searches were based on citations and references found in located articles. Of 53 retrieved publications, five met inclusion criteria.

DATA EXTRACTION

Data were extracted and organised under the following headings: GDM rates among women born in SEA; screening for GDM; and characteristics of GDM risk for SEA born women. Study quality was assessed by using the CASP (Critical Appraisal Skills Programme) guidelines.

DATA SYNTHESIS

This review produced three main findings: (1) compared to combined Asian groups, GDM rates were lower among SEA women; (2) compared to other Asian sub-groups, GDM rates among SEA women were in the intermediate range; and (3) SEA born women demonstrated consistently higher rates of GDM than women from the same ethnic background who were born in countries such as the US, UK or Australia.

CONCLUSIONS

From this review, it was clear that a 'one size fits all' approach to Asian ethnicity was not useful for estimating GDM rates among SEA women. There was also considerable difference among women of SEA ethnicity born in South East Asia, compared to women of the same ethnic background born in developed countries. Future research should explore the unique characteristics of GDM risk for these women. Such information is necessary for the development of strategies for the prevention and treatment of GDM among SEA women.

Physical activity and pregnancy: past and present evidence and future recommendations

PURPOSE

In this review, we provide researchers and practitioners with an overview of the physical activity and pregnancy literature to promote prenatal physical activity, improve measurement, further elucidate the role of activity in reducing maternal health complications, and inform future research.

METHOD

We examined past and present physical activity and pregnancy studies and highlight key papers with a focus on maternal health outcomes to best inform physical activity promotion efforts.

RESULTS

We discuss: (a) historical overview of prenatal physical activity relative to the physical activity guidelines, how they have changed over time, and how evidence of the effect of prenatal activity on maternal/fetal health outcomes has affected clinical recommendations; (b) existing tools and challenges associated with measuring prenatal physical activity; (c) empirical evidence on multilevel determinants of prenatal activity to guide future intervention work; (d) empirical evidence of prenatal activity on adverse maternal outcomes (gestational diabetes mellitus, preeclampsia, excessive gestational weight gain) from observational and intervention studies; and (e) summary/recommendations for future research and practice.

CONCLUSIONS

The physical activity and pregnancy literature has evolved over the past 50 years, and there is sufficient empirical evidence to support the promotion of moderate-to-vigorous prenatal physical activity for maternal health benefits. Future studies and interventions should be carefully designed, theoretically driven, and include validated and reliable activity measures. Researchers and practitioners should also consider the multifaceted determinants and outcomes of prenatal physical activity and intervene to promote physical activity before, during, and after pregnancy.

Physician care patterns and adherence to postpartum glucose testing after gestational diabetes mellitus in Oregon

OBJECTIVE

This study examines obstetrician/gynecologists and family medicine physicians' reported care patterns, attitudes and beliefs and predictors of adherence to postpartum testing in women with a history of gestational diabetes mellitus.

RESEARCH DESIGN AND METHODS

In November-December 2005, a mailed survey went to a random, cross-sectional sample of 683 Oregon licensed physicians in obstetrician/gynecologists and family medicine from a population of 2171.

RESULTS

Routine postpartum glucose tolerance testing by both family physicians (19.3%) and obstetrician/gynecologists physicians (35.3%) was reportedly low among the 285 respondents (42% response rate). Factors associated with high adherence to postpartum testing included physician stated priority (OR 4.39, 95% CI: 1.69-7.94) and physician beliefs about norms or typical testing practices (OR 3.66, 95% CI: 1.65-11.69). Specialty, sex of physician, years of practice, location, type of practice, other attitudes and beliefs were not associated with postpartum glucose tolerance testing.

CONCLUSIONS

Postpartum glucose tolerance testing following a gestational diabetes mellitus pregnancy was not routinely practiced by responders to this survey. Our findings indicate that physician knowledge, attitudes and beliefs may in part explain suboptimal postpartum testing. Although guidelines for postpartum care are established, some physicians do not prioritize these guidelines in practice and do not believe postpartum testing is the norm among their peers.

The IDEAL study: investigation of dietary advice and lifestyle for women with borderline gestational diabetes: a randomised controlled trial - study protocol

BACKGROUND

The Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) showed that treatment of pregnant women with mild gestational diabetes mellitus is beneficial for both women and their infants. It is still uncertain whether there are benefits of similar treatment for women with borderline gestational diabetes.This trial aims to assess whether dietary and lifestyle advice and treatment given to pregnant women who screen for borderline gestational diabetes reduces neonatal complications and maternal morbidities.

METHODS/DESIGN

DESIGN

Multicentre, randomised controlled trial.

INCLUSION CRITERIA

Women between 240 and 346 weeks gestation with a singleton pregnancy, a positive oral glucose challenge test (venous plasma glucose ≥7.8 mmol/L) and a normal oral 75 gram glucose tolerance test (fasting venous plasma glucose <5.5 mmol/L and a 2 hour glucose <7.8 mmol/L) with written, informed consent.Trial entry and randomisation: Women with an abnormal oral glucose tolerance test (fasting venous plasma glucose ≥5.5 mmol/L or 2 hour glucose ≥7.8 mmol/L) will not be eligible and will be offered treatment for gestational diabetes, consistent with recommendations based on results of the ACHOIS trial. Eligible women will be randomised into either the 'Routine Care Group' or the 'Intervention Group'.Study groups: Women in the 'Routine Care Group' will receive routine obstetric care reflecting current clinical practice in Australian hospitals. Women in the 'Intervention Group' will receive obstetric care, which will include dietary and lifestyle advice, monitoring of blood glucose and further medical treatment for hyperglycaemia as appropriate.Primary study outcome: Incidence of large for gestational age infants.

SAMPLE SIZE

A sample size of 682 women will be sufficient to show a 50% reduction in the risk of large for gestational age infants (alpha 0.05 two-tailed, 80% power, 4% loss to follow up) from 14% to 7% with dietary and lifestyle advice and treatment.

DISCUSSION

A conclusive trial outcome will provide reliable evidence of relevance for the care of women with borderline glucose intolerance in pregnancy and their infants.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry - ACTRN12607000174482.

Determinants of postpartum physical activity, dietary habits and weight loss after gestational diabetes mellitus

AIM

To describe the most significant findings of the studies that examined the prevalence and determinants of postpartum health behaviours (physical activity, dietary habits and/or weight loss) in patients with gestational diabetes mellitus (GDM).

BACKGROUND

Patients with gestational diabetes have a high risk of developing type 2 diabetes in the months after delivery. For this reason, GDM patients are encouraged to practice specific health behaviours during the postpartum period. It is important to identify the factors that may impact the adherence to these behaviours.

EVALUATION

Eighteen published research articles that examined postpartum health behaviours and/or their potential determinants in women diagnosed with GDM were selected from electronic databases.

KEY ISSUES

Physical activity and diet rarely meet the recommendations. Risk perception, health beliefs, social support and self-efficacy are the main factors identified as having an impact on the adoption of health behaviours. However, the cross-sectional nature of the studies and the lack of social, geographical and/or ethnic variety in the populations studied do not allow us to generalize the conclusions.

IMPLICATIONS FOR NURSING MANAGEMENT

This literature review reports all the information currently available that can enable nurses and midwives to engage in the evaluation and optimization of their interventions in GDM patients. Motivational interventions based on Social Cognitive Theory are proposed.

Women's experiences of factors that facilitate or inhibit gestational diabetes self-management

BACKGROUND

Gestational diabetes rates have increased dramatically in the past two decades and this pattern of increase appears to relate primarily to the obesity epidemic, older maternal age and migration from world areas of high GDM risk. Women from disadvantaged and migrant backgrounds are most at risk of developing and of mismanaging this condition. The aim of the study was to explore the factors that facilitated or inhibited gestational diabetes self-management among women in a socially deprived area.

METHODS

Fifteen pregnant women, with a diagnosis of gestational diabetes, were purposively recruited for this study. Qualitative semi structured interviews and 1 focus group were conducted when participants were approximately 28-38 weeks gestation. The study's theoretical framework was based on interpretative phenomenology and data was analysed using a thematic analysis approach.

RESULTS

Women in this study identified a number of factors that complicated their task of GDM self-management. Barriers included: (1) time pressures; (2) physical constraints; (3) social constraints; (4) limited comprehension of requirements, and (5) insulin as an easier option. Factors facilitating GDM self-management included: thinking about the baby and psychological support from partners and families.

CONCLUSION

Women from low socio economic and migrant backgrounds often struggle to comprehend GDM self-management requirements. To improve adherence to management plans, these women require educational and supportive services that are culturally appropriate and aimed at a low level of literacy.

Racial differences in the association between gestational diabetes mellitus and risk of type 2 diabetes

BACKGROUND

It is recognized that a history of gestational diabetes mellitus (GDM) predicts incident type 2 diabetes in women. However, it is unclear if there is a racial disparity between the association of GDM and type 2 diabetes.

METHODS

We studied 1,142 women with a history of GDM and 18,856 women without a history of GDM aged 13-50 years with their first record of pregnancy in Louisiana State University Hospital-Based Longitudinal Study database between 1990 and 2009. History of GDM was used to predict incident type 2 diabetes.

RESULTS

During a mean follow-up of 8.6 years, 1,394 women developed type 2 diabetes. The multivariable adjusted hazard ratio (HR) of type 2 diabetes was 6.52 (95% confidence interval [CI] 5.73-7.43) among women with GDM compared to women without GDM. Stratification by age, race, and body mass index (BMI) gave similar results. Compared with African American and white women without a history of GDM, the relative risk for type 2 diabetes was higher in African American women than in white women with a history of GDM. Compared with non-GDM women compartments, GDM women after delivery for <1, 1.0-3.9, 4.0-5.9, 6.0-7.9, 8-9.9, and ≥10.0 years had 4.00, 5.44, 4.26, 3.16, 4.49, and 4.17 times higher risk of having type 2 diabetes, respectively.

CONCLUSIONS

A history of GDM is a strong predictor of subsequent type 2 diabetes among Louisiana women, especially among African American women.

Previous gestational diabetes is independently associated with increased carotid intima-media thickness, similarly to metabolic syndrome - a case control study

Background

Women with previous gestational diabetes mellitus (pGDM) face a higher risk of developing type 2 diabetes and, consequently, a higher cardiovascular risk. This study aimed to compare the carotid intima-media thickness (cIMT) from young women with pGDM to those with metabolic syndrome (MS) and to healthy controls (CG) to verify whether a past history of pGDM could be independently associated with increased cIMT.

Methods

This is a cross-sectional study performed in two academic referral centers. Seventy-nine women with pGDM, 30 women with MS, and 60 CG aged between 18 and 47 years were enrolled. They all underwent physical examination and had blood glucose, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol (LDLc), and triglycerides determined. The cIMT was measured by ultrasound in several carotid segments. The primary endpoint was cIMT and clinically relevant parameters included as predictors were: age, systolic blood pressure, waist, BMI, total cholesterol, LDLc, triglycerides, fasting glucose, previous history of GDM as a whole group, previous history of GDM without MS, presence of DM, presence of MS, and parity.

Results

cIMT was significantly higher in pGDM when compared to CG in all sites of measurements (P < 0.05) except for the right common carotid. The pGDM women showed similar cIMT measurements to MS in all sites of measurements, except for the left carotid bifurcation, where it was significantly higher than MS (P < 0.001). In a multivariate analysis which included classical cardiovascular risk factors and was adjusted for confounders, pGDM was shown to be independently associated with increased composite cIMT (P < 0.01). The pGDM without risk factors further showed similar cIMT to MS (P > 0.05) and an increased cIMT when compared to controls (P < 0.05).

Conclusions

Previous GDM was independently associated with increased composite cIMT in this young population, similarly to those with MS and regardless the presence of established cardiovascular risk factors.

The influence of ethnicity on the development of type 2 diabetes mellitus in women with gestational diabetes: a prospective study and review of the literature

As the worldwide prevalence of type 2 diabetes continues to rise at an alarming rate, the search for susceptible populations likely to benefit from preventative measures becomes more important. One such population is women with a previous history of gestational diabetes mellitus (GDM). In this prospective study of 101 women who had GDM in Australia, ethnicity was a major risk factor for the development of diabetes following a diagnosis of GDM. With a mean followup of 5.5 years after GDM, South Asian women had a significantly higher risk of developing abnormal glucose tolerance (AGT) (69%) than women of all other ethnicities (P < 0.05). The prevalence of diabetes and impaired glucose tolerance was also very high amongst other groups: South East and East Asian (11/27, 41%), Middle-Eastern (8/18, 44%), South European backgrounds (5/12, 42%), and Australian-born women 39% (11/28). A review of the literature supports the role of ethnicity in the development of diabetes amongst these women. These findings have implications for South Asian countries and countries such as Australia where there is a population from diverse ethnic backgrounds and where the implementation of targeted measures to stem the growing tide of diabetes is needed.

Gestational Diabetes

Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy and is strongly related to subsequent risk of type 2 diabetes. The epidemics of obesity and diabetes and the increasing incidence of GDM in recent years highlight the importance of preventing GDM among women at high risk to avoid the associated short- and long-term adverse health outcomes for both mothers and their offspring. Indeed, women may be more likely to adopt healthy lifestyle habits during pregnancy and maintain these habits into the postpartum period. Although there is substantial evidence that targeting at-risk groups for type 2 diabetes prevention is effective if lifestyle changes are made, relatively little attention has been paid to the prevention of GDM. Therefore, the objective of this article is to review the scientific evidence regarding the association between modifiable risk factors and GDM; discuss how lifestyle interventions, including weight management through diet and exercise could be successful in reducing the risk for GDM; and provide recommendations for future lifestyle intervention programs with a focus on translation and dissemination of research findings.

Atlantic DIP: high prevalence of abnormal glucose tolerance post partum is reduced by breast-feeding in women with prior gestational diabetes mellitus

OBJECTIVE

Gestational diabetes (GDM) is associated with adverse fetal and maternal outcomes, and identifies women at risk of future type 2 diabetes mellitus (T2DM). Breast-feeding may improve post partum maternal glucose tolerance. Our objective was to identify the prevalence of post partum dysglycemia after GDM, to delineate associated factors and to examine the effect of lactation on post partum glucose tolerance.

DESIGN

We compared post partum 75 g oral glucose tolerance test (OGTT) results from 300 women with GDM and 220 controls with normal gestational glucose tolerance (NGT) in five regional centers. Breast-feeding data was collected at time of OGTT. Methods Post partum OGTT results were classified as normal (fasting plasma glucose (FPG) <5.6 mmol/l, 2 h <7.8 mmol/l) and abnormal (impaired fasting glucose (IFG), FPG 5.6-6.9 mmol/l; impaired glucose tolerance (IGT), 2 h glucose 7.8-11 mmol/l; IFG+IGT; T2DM, FPG ≥7 mmol/l±2 h glucose ≥11.1 mmol/l). Binary logistic regression was used to identify factors predictive of persistent hyperglycemia.

RESULTS

Five hundred and twenty women were tested; six (2.7%) with NGT in pregnancy had post partum dysglycemia compared with 57 (19%) with GDM in index pregnancy (P<0.001). Non-European ethnicity (odds ratio (OR) 3.40; 95% confidence interval (CI) 1.45-8.02, P=0.005), family history of T2DM (OR 2.14; 95% CI 1.06-4.32, P=0.034), and gestational insulin use (OR 2.62; 95% CI 1.17-5.87, P=0.019) were associated with persistent dysglycemia. The prevalence of persistent hyperglycemia was significantly lower in women who breast-fed vs bottle-fed post partum (8.2 vs 18.4%, P<0.001).

CONCLUSIONS

Non-European ethnicity, gestational insulin use, family history of T2DM, and elevated body mass index were associated with persistent dysglycemia after GDM. Breast-feeding may confer beneficial metabolic effects after GDM and should be encouraged.

Stressful events, smoking exposure and other maternal risk factors associated with gestational diabetes mellitus

The incidence of gestational diabetes mellitus (GDM) has increased significantly in the last few decades in the US. Understanding its risk factors is imperative for the prevention of GDM and its sequelae, but the roles of behavioural risk factors such as stressful events and smoking on GDM are generally not well understood. Using data obtained from the New York State (NYS) Pregnancy Risk Assessment Monitoring System survey for 2004-06 and the NYS birth certificates, we examined relationships between GDM, stressful events and smoking among 2690 women who had live singleton births and did not have pre-pregnancy diabetes. After adjustment for risk factors such as maternal age, race/ethnicity, pre-pregnancy body mass index, hypertension, as well as smoking exposure, education, parity, and gestation at first visit for prenatal care, we found that having five or more stressful events 12 months before the baby was born was significantly associated with GDM (OR = 2.49, [95% CI 1.49, 4.16]). In another model, having any stressful event(s) other than 'moved to a new address' 12 months before the baby was born was also moderately associated with GDM (OR = 1.38, [95% CI 1.04, 1.85]). Smoking exposure, assessed by combining maternal smoking and second-hand smoke exposure into six levels, had no significant association with GDM, and did not show a dose-response pattern. The present study suggests that stressful events during pregnancy may be an independent risk factor for GDM. Future studies of GDM should include this common, but potentially modifiable risk factor in analyses.

Evaluation of postpartum carbohydrate intolerance and cardiovascular risk factors in women with gestational diabetes

We aimed to evaluate the predictors of subsequent development of postpartum carbohydrate intolerance, metabolic syndrome and cardiovascular risk factors in women with previous GDM. Two hundred fifty-two consecutive women with GDM were enrolled. After exclusion of women who did not attend to the hospital for follow-up visits for minimum 1 year, data of 195 patients were evaluated. Seventy-one lean women with negative screening for GDM were included as a control group. The prevalence of diabetes, impaired glucose tolerance and impaired fasting glucose and metabolic syndrome was significantly higher in women with previous GDM than healthy controls. Women with previous GDM were more insulin resistant, had an atherogenic lipid profile and increased carotid IMT. The most important predictors of postpartum diabetes were the need for insulin treatment during index pregnancy and glucose values on antepartum OGTT. Among women with previous GDM, the development of postpartum diabetes and metabolic syndrome was associated with increased carotid IMT. Our data show that women with previous GDM are at high risk for developing carbohydrate intolerance, metabolic syndrome and atherosclerosis. Antepartum prediction of high risk subjects for the subsequent development of postpartum carbohydrate intolerance and metabolic syndrome seems to be vital to prevent cardiovascular outcomes.

Outcomes in women with a history of gestational diabetes. Screening and prevention of type 2 diabetes. Literature review

Women with a history of gestational diabetes mellitus (GDM) are characterized by a high risk of type 2 diabetes mellitus (T2DM) (x 7), metabolic syndrome (x 2 to 5) and cardiovascular diseases (x 1,7). Women with lesser degrees of glucose intolerance share the same risks. T2DM may occur from post-partum (5 to 14%) to several years later, up to 25 years. Some factors associated with T2DM are identified: obesity, early diagnosis of GDM before 24 weeks gestation, high pregnancy OGTT blood glucose or insulin-therapy during GDM. Screening for T2DM only with fasting glucose provides less sensibility than with OGTT; HbA1c may supplant these dosages. The recurrence rate of GDM is between 30 and 84%, non-white ethnicity and insulinotherapy during GDM being the best proven predictors. High risk women need repeated life-long screenings for glycaemic abnormalities, or when another pregnancy is planned. Among obese women with history of GDM who show minor glycoregulation disturbances, modifications of lifestyle in intensive programs or metformin halve the risk of DT2. However, studies analysing practices show low adhesion to screening; without an intensive program, few women implement lifestyle modifications. These intensive programs should be implemented and proposed to high-risk women. Their therapeutic education should also include prevention of cardiovascular risk factors.

A pilot structured behavioural intervention trial to increase physical activity among women with recent gestational diabetes

Forty-three women were recruited into a 1-year randomised controlled trial to test the feasibility of a structured behavioural intervention to increase physical activity after gestational diabetes. Increases in achievement of physical activity targets were not attained. Recruitment and subject retention were identified as major challenges.

Feasibility of a lifestyle intervention in early pregnancy to prevent deterioration of glucose tolerance

Background

In conjunction with the growing prevalence of obesity and the older age of pregnant women gestational diabetes (GDM) is a major health problem.

The aim of the study was to evaluate if a lifestyle intervention since early pregnancy is feasible in improving the glucose tolerance of women at a high-risk for GDM in Finland.

Methods

A 75-g oral glucose tolerance test (OGTT) was performed in early pregnancy (n = 102). Women at high risk for GDM (n = 54) were randomized at weeks 8-12 from Apr 2005 to May 2006 to a lifestyle intervention group (n = 27) or to a close follow-up group (n = 27). An OGTT was performed again at weeks 26-28 for the lifestyle intervention and close follow-up groups.

Results

The values of the OGTT during the second trimester did not differ between the lifestyle intervention and close follow-up groups. In the lifestyle intervention group three women had GDM in the second trimester and respectively one woman in the close follow up group. Insulin therapy was not required in both groups. The intervention resulted in somewhat lower weight gain 11.4 ± 6.0 kg vs. 13.9 ± 5.1 kg, p = 0.062, adjusted by the prepregnancy weight.

Conclusions

Early intervention with an OGTT and simple lifestyle advice is feasible. A more intensive lifestyle intervention did not offer additional benefits with respect to glucose tolerance, although it tended to ameliorate the weight gain.

Trial Registration

ClinicalTrials.gov: NCT01130012

Gestational diabetes history may signal deprivation in women with type 2 diabetes

BACKGROUND

There is a higher prevalence of type 2 diabetes in lower income groups, particularly in women. Gestational diabetes (diabetes during pregnancy) has also been associated with lower income levels. What has not been studied is whether a past history of gestational diabetes retains an inverse association with income among women with type 2 diabetes.

METHODS

Among women with type 2 diabetes, we assessed for an association between history of gestational diabetes and lower income/lower educational attainment (multiple waves of Canadian Community Health Survey [CCHS]) through logistic regression models adjusted for age, body mass index (BMI), immigrant and marital status, smoking history, and physical activity.

RESULTS

Compared to women in the highest income group, a gestational diabetes history was 71% more likely in the lower middle income group (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.06-2.74) and nearly two times more likely in the lowest income group (OR 1.94, 95% CI 1.15-3.27). Associations with education were inconclusive. Compared to married women, single women (divorced/separated/never married) were nearly two times more likely to have a gestational diabetes history (OR 1.71, 95% CI 1.17-2.49).

CONCLUSIONS

These findings indicate that women with diabetes and past history of gestational diabetes constitute a particularly deprived group. A gestational diabetes history in women with type 2 diabetes may signal a need to assess and address material resources and social support as part of the diabetes management plan.

Pregnancy-induced hypertension, but not gestational diabetes mellitus, is a risk factor for venous thromboembolism in pregnancy

Background and Objectives

The aim of this study was to identify the association of pregnancy-induced hypertension (PIH) or gestational diabetes mellitus (GDM) with the development of venous thromboembolism (VTE).

Subjects and Methods

This was a retrospective study of 57,009 pregnancies during 2002-2008 at Cheil General Hospital, Kwandong University. The diagnosis of VTE {deep vein thrombosis or pulmonary embolism (PE)} was based on clot visualization via ultrasound or computed tomography.

Results

In total, 27 cases (PE, 20 cases) were detected. The incidence of VTE was 0.47 per 1,000 pregnancies. To determine risk factors associated with pregnancy-induced VTE, univariate analysis using a chi-square test was performed. Cesarean (C)-section, multiple pregnancy, PIH, placenta previa, and assisted reproduction technique (ART) were statistically significant compared to the controls (all, p=0.000). However, age, premature rupture of membrane, and GDM were not statistically related to VTE. Logistic regression analysis was used to calculate the odds ratios for the risk factors. Placenta previa showed a 12.6-fold higher risk, while PIH had a 9.8-fold higher risk for the occurrence of VTE. C-section and ART procedures increased the risk of VTE by 4.2 times compared to that of the controls.

Conclusion

Placenta previa and PIH were significant risk factors for VTE, whereas the known traditional risk factors of increased age and GDM were not found to be associated with VTE.

Does exercise have a role in the management of gestational diabetes mellitus?

Gestational diabetes mellitus (GDM) is associated with a marked increase in the long-term risk of type 2 diabetes and adverse pregnancy outcomes. Engaging in vigorous recreational physical activity prior to and during pregnancy significantly reduces the risk of developing GDM. In contrast, evidence of a therapeutic effect from participation in a structured exercise training regimen, although promising, is limited and requires further more substantial investigation. This paper briefly reviews the pathophysiology of GDM, the evidence related to physical activity participation and exercise regimen intervention on GDM, and the clinical considerations required for prescribing exercise.

[Outcomes in women with history of gestational diabetes mellitus. Screening and prevention of type 2 diabetes mellitus. Literature review]

Women with a history of gestational diabetes mellitus (GDM) are characterized by a high risk of type 2 diabetes mellitus (T2DM) (X 7), metabolic syndrome (X 2 to 5) and cardiovascular diseases (X 1,7). Women with lesser degrees of glucose intolerance share the same risks. T2DM may occur from postpartum (5 to 14%) to several years later, up to 25 years. Some factors associated with T2DM are identified: obesity, early diagnostic before 24 weeks, high pregnancy OGTT blood glucose or insulinotherapy. Screening for T2DM only with fasting glucose provides less sensibility than with OGTT; HbA1c may supplant these dosages. The recurrence rate of GDM is between 30 and 84%, non-white ethnicity and insulinotherapy during GDM being the best proven predictors. High risk women need repeated life-long screenings for glycemic abnomalies, or when another pregnancy is planned. Among overweight or obese women with history of GDM who show minor glycoregulation disturbances, it is proved that modifications of lifestyle in intensive programs or metformin halve the risk of DT2. However, studies analysing practices show low adhesion to screening; without an intensive program, few women implement lifestyle modifications. These intensive programs should be implemented and proposed to high-risk women. Their therapeutic education should also include prevention of cardiovascular risk factors.

Metformin should be considered in the treatment of gestational diabetes: a prospective randomised study

OBJECTIVE

To examine if oral metformin is as effective as insulin in the prevention of fetal macrosomy in pregnancies complicated with gestational diabetes mellitus (GDM).

DESIGN

Open-label prospective randomised controlled study.

SETTING

Maternity outpatient clinics in a secondary and tertiary level hospital in Finland.

SAMPLE

One hundred women with GDM who did not attain euglycaemia with diet.

METHODS

Women were randomised to therapy with insulin (n = 50) or oral metformin (n = 50).

MAIN OUTCOME MEASURES

Incidence of large-for-gestational-age (LGA) infants and neonatal morbidity.

RESULTS

There were no statistically significant differences in the incidence of LGA (8.5 versus 10.0%, P = 0.97), mean birthweight, mean cord artery pH or neonatal morbidity between the insulin and metformin groups. Fifteen (31.9%) of the 47 women randomised to metformin needed supplemental insulin. They were more obese (with a body mass index of 36 versus 30 kg/m(2), P = 0.002), had higher fasting blood glucose levels in an oral glucose tolerance test (6.1 versus 5.0 mmol/l, P = 0.001) and needed medical treatment for GDM earlier (26 versus 31 gestational weeks, P = 0.002) than women who were normoglycemic with metformin. There was a tendency to a higher rate of caesarean sections in the metformin group than in the insulin group (RR 1.9; 95% CI 0.99-3.71).

CONCLUSIONS

Metformin seems to be suitable for the prevention of fetal macrosomy, especially in lean or moderately overweight women developing GDM in late gestation. Women with considerable obesity, high fasting blood glucose and an early need for pharmacological treatment may be more suitable for insulin therapy.

One-hour post-glucola results and pre-pregnancy body mass index are associated with the need for insulin therapy in women with gestational diabetes

OBJECTIVE

The purpose of this study was to analyze the relationship of 1-h post-glucola (PG) screening results and the need for insulin therapy in women with gestational diabetes (GDM).

METHODS

The study group was comprised of women with GDM treated at a single institution during calendar years 2000-2004. Women with singleton, term (≥ 37 weeks gestation), liveborn fetuses were included. The association of 1-h PG results and other perinatal risk factors to the need for subsequent insulin therapy was analyzed using multivariable logistic regression models.

RESULTS

Of the 1451 women were included in the analysis, 18.1% required insulin treatment. The mean 1-h PG result was 170.0 ± 26.1 mg/dl (range 140-414 mg/dl). We determined that a 1-h PG ≥ 190 mg/dl (p < 0.0001), an obese body mass index (BMI) (p < 0.0001), an overweight BMI (p = 0.0019), prior GDM (p = 0.0019), and prior macrosomia (p = 0.0210) were each highly associated with the need for subsequent insulin therapy during the pregnancy.

CONCLUSIONS

A 1-h PG ≥ 190 mg/dl was strongly associated with the need for insulin therapy in women with GDM. These data may be helpful in counseling and managing women with GDM.

Gestational diabetes: risks, management, and treatment options

Gestational diabetes mellitus (GDM) is commonly defined as glucose intolerance first recognized during pregnancy. Diagnostic criteria for GDM have changed over the decades, and several definitions are currently used; recent recommendations may increase the prevalence of GDM to as high as one of five pregnancies. Perinatal complications associated with GDM include hypertensive disorders, preterm delivery, shoulder dystocia, stillbirths, clinical neonatal hypoglycemia, hyperbilirubinemia, and cesarean deliveries. Postpartum complications include obesity and impaired glucose tolerance in the offspring and diabetes and cardiovascular disease in the mothers. Management strategies increasingly emphasize optimal management of fetal growth and weight. Monitoring of glucose, fetal stress, and fetal weight through ultrasound combined with maternal weight management, medical nutritional therapy, physical activity, and pharmacotherapy can decrease comorbidities associated with GDM. Consensus is lacking on ideal glucose targets, degree of caloric restriction and content, algorithms for pharmacotherapy, and in particular, the use of oral medications and insulin analogs in lieu of human insulin. Postpartum glucose screening and initiation of healthy lifestyle behaviors, including exercise, adequate fruit and vegetable intake, breastfeeding, and contraception, are encouraged to decrease rates of future glucose intolerance in mothers and offspring.

Barriers to follow-up for women with a history of gestational diabetes

Women with gestational diabetes (GDM) are at increased risk for type 2 diabetes (T2DM), but many do not receive recommended follow-up. We sought to identify barriers to follow-up screening. We surveyed primary care providers (PCPs) and obstetric and gynecology care providers (OBCPs) in a large health system. We also assessed documentation of GDM history in the health care system's electronic medical record. Four hundred seventy-eight clinicians were surveyed, among whom 207 responded. Most participants (81.1%) gave an accurate estimate of risk of progression to T2DM. PCPs were less likely than OBCPs to ask patients about history of GDM (odds ratio [OR] 0.43, 95% confidence interval [CI] 0.20 to 0.90), but they were far more likely to indicate that they order glucose screening for women with a known history (OR 4.31, 95% CI 2.01 to 9.26). Providers identified poor communication between OBCPs and PCPs as a major barrier to screening. Fewer than half (45.8%) of 450 women with GDM by glucose tolerance test criteria had that history documented on their electronic problem list. Clinicians are aware that women with GDM are at high risk of developing type 2 diabetes, but they do not routinely assess and screen patients, and communication between OBCPs and PCPs can be improved.

Gestational diabetes mellitus: simplifying the international association of diabetes and pregnancy diagnostic algorithm using fasting plasma glucose

OBJECTIVE

To determine the impact of the International Association of Diabetes and Pregnancy Study Group (IADPSG) criteria on 1) gestational diabetes mellitus (GDM) diagnosis compared with the American Diabetes Association (ADA) criteria and 2) the fasting plasma glucose (FPG) to predict GDM.

RESEARCH DESIGN AND METHODS

In 10,283 pregnant women undergoing a 75-g oral glucose tolerance test (OGTT) for universal screening of GDM, two FPG thresholds (of the OGTT) were used to rule in and to rule out GDM.

RESULTS

The IADPSG and ADA criteria identified GDM in 3,875 (37.7%) women and 1,328 (12.9%) women, respectively (P < 0.0005). FPG thresholds of >or=5.1 mmol/l ruled in GDM in 2,975 (28.9%) women with 100% specificity, while <4.4 mmol/l ruled out GDM in 2,228 (21.7%) women with 95.4% sensitivity. FPG independently could have avoided the OGTT in 5,203 (50.6%) women.

CONCLUSIONS

The IADPSG criteria increased GDM prevalence nearly threefold. By circumventing a significant number of OGTTs, an initial FPG can greatly simplify the IADPSG diagnostic algorithm.

Perceived risk of Type 2 diabetes in Australian women with a recent history of gestational diabetes mellitus

AIMS

To describe the risk perceptions and factors associated with a high level of perceived risk for the development of Type 2 diabetes in a sample of Australian women with a recent history of gestational diabetes mellitus.

METHODS

Participants were women aged 18 years and over, diagnosed with gestational diabetes between 2003 and 2005, registered with the National Diabetes Services Scheme. Cross-sectional data were collected via written postal survey and included a self-reported risk perception scale.

RESULTS

Of 4098 invited, eligible women, 1372 consented to participate (response rate 36%). Respondents currently pregnant or subsequently diagnosed with Type 2 diabetes were excluded (n = 196). Up to 3 years post-gestational diabetes, 32% of women perceived that they were at a low or very low risk for developing Type 2 diabetes, 42% at moderate risk and 26% high or very high risk. Using logistic regression analysis, factors associated with high level of perceived risk were body mass index > 25 kg/m(2) [odds ratio (OR) 4.50, 95% confidence interval (CI) (3.12, 6.51)], a family history of diabetes [OR 3.80, 95% CI (2.67, 5.33)] and use of insulin during pregnancy [OR 1.92, 95% CI (1.31, 2.61)].

CONCLUSIONS

Although women with known risk factors for Type 2 diabetes were more likely to perceive their risk as high, we found that one third still considered themselves to be at low or very low risk for the development of diabetes. These results suggest a need for increased awareness of gestational diabetes as a strong predictor of Type 2 diabetes risk.

The risk of overt diabetes mellitus among women with gestational diabetes: a population-based study

AIMS

To determine the incidence of postpartum diabetes mellitus in the years following a diagnosis of gestational diabetes mellitus (GDM) and to determine whether the severity of GDM, represented by the magnitude of the deviation of diagnostic tests from the normal values or requirement for medications, is associated with the development of diabetes.

METHODS

A retrospective cohort study was performed among 185 416 pregnant women who had glucose challenge test or 3 h oral glucose tolerance test (OGTT) in a large health maintenance organization in Israel. Subsequent diagnosis of diabetes was ascertained by using an automated patient registry.

RESULTS

A total of 11 270 subjects were diagnosed with GDM, comprising 6.07% of the cohort. During a total follow-up period of 1 049 334 person-years there were 1067 (16.9 per 1000 person-years) and 1125 (1.1 per 1000 person-years) diagnoses of postpartum diabetes among GDM and non-GDM women, respectively. The cumulative risk of incident diabetes in GDM patients with up to 10 years of follow-up was 15.7%, compared with 1% among the non-GDM population. Gestational diabetes mellitus was associated with nearly an eightfold higher risk of postpartum diabetes after adjusting for important confounders, such as socioeconomic status and body mass index. Among women with a history of GDM, the number of abnormal OGTT values and use of insulin were associated with a substantially higher risk for developing diabetes.

CONCLUSIONS

Three or four abnormal OGTT values and GDM requiring insulin or oral hypoglycaemic medications are important predictors of postpartum diabetes risk in women with a history of GDM.

A simple risk score to identify Southern Chinese at high risk for diabetes

AIMS

To develop a simple scoring system for identifying Southern Chinese at risk of diabetes.

METHODS

The score was derived from a risk factor matching cohort for Type 2 diabetes in Hong Kong Chinese (cohort 1, 2448 subjects without a history of diabetes; age, mean +/- sd 37.2 +/- 8.9 years, median 36.0 years; 1649 had risk factors for diabetes and 799 were age-matched control subjects from the community). Two other cohorts were used to validate the risk score (cohort 2, 3734 subjects with risk factors for diabetes; and cohort 3, 1513 participants of a community diabetes survey). All subjects had a 75 g oral glucose tolerance test (OGTT).

RESULTS

In cohort 1, 270 (11%) of the subjects were found to have diabetes on OGTT. A risk score system was derived using the beta values of the corresponding predictors in the logistic regression analysis. The area under the curve (95% confidence intervals) of the score system was 0.735 (0.705, 0.765). The application of a risk score of > or = 16 increased the detection rate 2.5-4 times in all three cohorts. A high post-test probability of diabetes of > 60% was derived from a risk score of > or = 20. Only 10-20 and approximately 5% with a score of > or = 12 and > or = 16, respectively, are indicated for OGTT. This will considerably improve the yield of OGTT screening.

CONCLUSIONS

A simple risk score identifies young-to-middle-aged Southern Chinese at high risk for diabetes. Subjects with a score of 16 or above (out of 30) should undergo OGTT for definitive diagnosis of diabetes.

Gestational diabetes screening after HAPO: has anything changed?

Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy. It is defined as diabetes that is first recognized during pregnancy. The diagnosis of GDM is important because it impacts maternal health care during and after pregnancy. The American Diabetes Association, American Congress of Obstetrics and Gynecology, the World Health Organization, and the National Diabetes Data Group all have recommendations for screening; however, there is no consensus. The Hyperglycemia and Adverse Pregnancy Outcome Research Cooperative Study Group published their findings that show hyperglycemia has a significant effect on pregnancy outcome. In addition, recent studies showed that treatment of mild hyperglycemia may affect adverse outcomes. However, at this time no new guidelines for screening and diagnosis of gestational diabetes have been published. This article summarizes the current state of screening for gestational diabetes.

Obesity and gestational diabetes

The prevalence of both obesity and gestational diabetes mellitus (GDM) is increasing worldwide. GDM affects about 7% of all pregnancies and is defined as any degree of impaired glucose tolerance during gestation. The presence of obesity has a significant impact on both maternal and fetal complications associated with GDM. These complications can be addressed, at least in part, by good glycaemic control during pregnancy. The significance and impact of obesity in women with GDM are discussed in this article, together with treatment options, the need for long-term risk modification and postpartum follow-up.