Impaired insulin-stimulated nonoxidative glucose metabolism in glucose-tolerant women with previous gestational diabetes

Increased pancreatic-derived factor (PANDER) levels in gestational diabetes mellitus

The aim of the study was to investigate the pancreatic-derived factor (PANDER) levels in healthy pregnant women and in pregnant women with gestational diabetes mellitus (GDM). A total of 50 women consecutively diagnosed with GDM and 30 randomly selected age-matched and gestational-age-matched healthy pregnant women were included in this cross-sectional study. Serum PANDER levels and other variables were analyzed. The age, the gestational age at the time, the blood sample was obtained and the hemoglobin A1c (HbA1c) levels of the GDM and control groups were similar. The body mass index (BMI), fasting blood glucose, insulin, homeostasis model assessment of insulin resistance (HOMA-IR), and serum PANDER levels were significantly higher in the GDM group than the control group. The optimal PANDER cutoff value was 227.2 ng/ml, and the ratios above this value were 100 and 86.6% for sensitivity and specificity, respectively (p=.0001). Serum PANDER levels were higher in women with GDM compared to the control group and were positively correlated with insulin, HOMA-IR, and HbA1c levels. These results suggest that PANDER might be considered a new biomarker for GDM.

Increased incidence of obstetric complications in women carrying mitochondrial DNA mutations: a retrospective cohort study in a single tertiary centre

OBJECTIVE

To investigate the obstetric outcome of women carriers of the oxidative phosphorylation (OXPHOS) disorder mutation.

DESIGN

A retrospective cohort study in a single tertiary centre.

SETTING

A review of the obstetric history of women referred for prenatal screening of a mitochondrial disorder was performed.

POPULATION

Women were divided into three groups: (1) women carrying mitochondrial DNA (mtDNA) mutations; (2) healthy women with a family history of mtDNA-related OXPHOS disorder; and (3) healthy women carrying heterozygote nuclear DNA mutations.

METHODS

Obstetric history and pregnancy complications were evaluated separately in the three groups and compared with the control group. MAIN OUTCOME MEASURES PREGNANCY COMPLICATIONS.

RESULTS

Seventy-five women were included with 287 cumulative pregnancies. Groups 1 and 3 had a significantly greater proportion of terminations of pregnancy (20 and 13% versus 0.8%, P < 0.001), and a lower percentage of live births (52 and 72% versus 87%, P = 0.001), compared with controls. Apart from this, the rate of obstetric complications in group 3 did not differ from the controls. The obstetric history of women in group 1 was marked by higher rates of early miscarriages (26 versus 11%, P = 0.004), gestational diabetes (14 versus 3%, P = 0.02), intrauterine growth restriction (IUGR, 10 versus 1%, P = 0.008), and postpartum haemorrhage than were reported for controls (12 versus 2%, P = 0.01).

CONCLUSION

Women who are heteroplasmic for OXPHOS mutations have a higher incidence of pregnancy losses, gestational diabetes, IUGR, and post postpartum haemorrhage.

TWEETABLE ABSTRACT

Women heteroplasmic for mitochondrial DNA mutations have a higher incidence of obstetric complications, compared with the control group.

The effect of a glucagon-like peptide-1 receptor agonist on glucose tolerance in women with previous gestational diabetes mellitus: protocol for an investigator-initiated, randomised, placebo-controlled, double-blinded, parallel intervention trial

INTRODUCTION

Pregnancy is associated with decreased insulin sensitivity, which is usually overcome by a compensatory increase in insulin secretion. Some pregnant women are not able to increase their insulin secretion sufficiently, and consequently develop gestational diabetes mellitus (GDM). The disease normally disappears after delivery. Nevertheless, women with previous GDM have a high risk of developing type 2 diabetes (T2D) later in life. We aim to investigate the early development of T2D in women with previous GDM and to evaluate whether treatment with the glucagon-like peptide-1 receptor (GLP-1R) agonist, liraglutide, may modify their risk of developing T2D.

METHODS AND ANALYSES

100 women with previous GDM will be randomised to either liraglutide or placebo treatment for 1 year (blinded) with an open-label extension for another 4 years. Additionally, 15 women without previous GDM will constitute a baseline control group. Women will be tested with an oral glucose tolerance test (primary endpoint: area under the curve for plasma glucose) and an isoglycaemic intravenous glucose infusion at baseline, after 1 year and after 5 years. Additional evaluations include a glucagon test, dual-energy X-ray absorptiometry, imaging of the liver (ultrasound elastography and fibroscanning), an ad libitum meal for food intake evaluation and questionnaires related to appetite, quality of life and alcohol consumption habits.

ETHICS AND DISSEMINATION

The protocol has been approved by the Danish Medicines Agency, the Scientific-Ethical Committee of the Capital Region of Denmark, and the Danish Data Protection Agency and will be carried out under the surveillance and guidance of the GCP unit at Copenhagen University Hospital Bispebjerg in compliance with the ICH-GCP guidelines and in accordance with the Helsinki Declaration. Positive, negative and inconclusive results will be published at scientific conferences and as one or more scientific manuscripts in peer-reviewed journals.

REGISTRATIONS

The trial is registered at https://eudract.ema.europa.eu (2012-001371-37) and http://www.clinicaltrials.gov (NCT01795248).

Insulin resistance as estimated by the homeostatic method at diagnosis of gestational diabetes: estimation of disease severity and therapeutic needs in a population-based study

BACKGROUND

Chronic insulin resistance, exacerbated in the course of pregnancy, is an important pathophysiologic mechanism of gestational diabetes mellitus (GDM). We hypothesise that the degree of insulin resistance, assessed at diagnosis of GDM, is a parameter of its pathophysiologic heterogeneity and/or severity. Thus, it offers potential to open new avenues for the personalization of therapy in affected women.

METHODS

1254 Polish Caucasian women with GDM were recruited into the study. The following parameters were assessed in the course of the study: body mass index (BMI), parity, weight gain during pregnancy, glycated haemoglobin, glucose level during an oral glucose tolerance test (OGTT), insulin, insulin resistance and insulin secretion. The severity of GDM was assessed based on insulin use and daily insulin dose during gestation. In order to evaluate insulin secretion and insulin resistance the homeostatic method was used (HOMA-B and HOMA-IR, respectively). We compared all the metabolic parameters and methods of treatment of GDM in women subdivided by quartiles of insulin resistance.

RESULTS

The HOMA-IR in the whole population ranged from 0.34 to 20.39. The BMI, fasting insulin, fasting glucose and insulin dose per day increased along with increasing quartiles (HOMA-IR > 1.29). We observed a decrease of HOMA-B in the third quartile (1.92-2.89) compared with the first quartile (0.34-1.29). Insulin treatment was associated with HOMA-IR (<1.29 vs. >2.89), OR: 3.37, fasting glucose (≤6.11 vs. >6.11 mmol/dl), OR: 2.61, age (≤30 vs. >30 y. o.), OR: 1.54, and BMI (<25 vs. ≥25 kg/m2), OR: 1.45. Maximum insulin dose was associated with HOMA-IR, OR: 2.00, after adjustment for family history of diabetes, and 2-h OGTT glucose.

CONCLUSION

Insulin resistance assessed by the HOMA index at diagnosis is associated with the severity and pathophysiological heterogeneity of GDM. A HOMA-IR >1.29 points to the major role of insulin resistance, indicating the need for a treatment aimed at improving tissue sensitivity to insulin. A HOMA-IR 1.29-2.89 suggests reduced insulin secretion, which is an indication for the introduction of insulin therapy. A HOMA-IR >2.89 indicates insufficient compensation for insulin resistance, which suggests the need for a treatment aimed at improving susceptibility of tissues to insulin combined with insulin therapy.

Carbohydrates, glycemic index, and pregnancy outcomes in gestational diabetes

This review critically evaluates the current evidence regarding the effect of the dietary glycemic index (GI) on pregnancy outcomes in gestational diabetes mellitus (GDM). Current evidence, although limited, consistently supports the advantages of, and has demonstrated no disadvantages of, a low-GI diet. We conclude that pregnant women with GDM are likely to benefit from following a low-GI meal pattern, with no significant side effects, and consideration of the GI should be given when formulating a diet for GDM. However, until larger scale intervention trials are completed, an exclusive low-GI diet should not replace the current recommended diets for GDM from relevant government and health agencies. Further studies that intervene at an earlier stage of pregnancy are required.

Gestational diabetes: pathogenesis and consequences to mother and offspring

Gestational diabetes mellitus (GDM) is defined as glucose intolerance with onset or first recognition during pregnancy. Data from Western countries suggest that the prevalence of GDM is increasing, being almost 10% of pregnancies and probably reflecting the global obesity epidemic. The majority of women with GDM seem to have beta-cell dysfunction that appears on a background of chronic insulin resistance already present before pregnancy. In less than 10% of GDM patients, defects of beta-cell function can be due to autoimmune destruction of pancreatic beta-cells, as in type 1 diabetes, or caused by monogenic mutations, as in several MODY subtypes. Diagnostic criteria for GDM vary worldwide and there are no clear-cut plasma glucose cut-off values for identifying women at a higher risk of developing macrosomia or other fetal complications. Because the oral glucose tolerance test (OGTT) is restricted to high risk individuals, 40% of GDM cases are left undiagnosed. Therefore, in high risk populations almost universal screening is recommended; only women considered to have very low risk do not need screening. Diet and exercise are the key elements in the treatment of GDM. If necessary, either insulin, certain oral hypoglycemic agents or combinations can be used to achieve normoglycemia. After delivery, women with GDM and their offspring have an increased risk for developing the metabolic syndrome and type 2 diabetes. Thus, pregnancy may act as a "stress test", revealing a woman's predisposition to T2D and providing opportunities for focused prevention of important chronic diseases.

Common type 2 diabetes risk gene variants associate with gestational diabetes

OBJECTIVE

We aimed to examine the association between gestational diabetes mellitus (GDM) and 11 recently identified type 2 diabetes susceptibility loci.

RESEARCH DESIGN AND METHODS

Type 2 diabetes risk variants in TCF7L2, CDKAL1, SLC30A8, HHEX/IDE, CDKN2A/2B, IGF2BP2, FTO, TCF2, PPARG, KCNJ11, and WFS1 loci were genotyped in a cohort of women with a history of GDM (n = 283) and glucose-tolerant women of the population-based Inter99 cohort (n = 2446).

RESULTS

All the risk alleles in the 11 examined type 2 diabetes risk variants showed an odds ratio (OR) greater than 1 for the GDM group compared with the control group ranging from 1.13 [95% confidence interval (CI) 0.88-1.46] to 1.44 (95% CI 1.19-1.74) except for the WFS1 rs10010131 variant with OR 0.87 (95% CI 0.73-1.05). Combined analysis of all 11 variants showed a highly significant additive effect of multiple risk alleles on risk of GDM [OR 1.18 (95% CI 1.10-1.27)] per risk allele, P = 3.2 x 10(-6)). Applying receiver-operating characteristic showed an area under the receiver-operating characteristic curve of 0.62 for the genetic test alone and 0.73 when combining information on age, body mass index, and genotypes of the 11 gene variants.

CONCLUSIONS

The prevalence in a prior GDM group of several previously proven type 2 diabetes risk alleles equals the findings from association studies on type 2 diabetes. This supports the hypothesis that GDM and type 2 diabetes are two of the same entity.

Value of the intravenous and oral glucose tolerance tests for detecting subtle impairments in insulin sensitivity and beta-cell function in former gestational diabetes

OBJECTIVE

Women with former gestational diabetes mellitus (fGDM) often show defects in both insulin sensitivity and beta-cell function but it is not clear which defect plays the major role or which appears first. This might be because fGDM women are often studied as a unique group and not divided according to their glucose tolerance. Different findings might also be the result of using different tests. Our aim was to study insulin sensitivity and beta-cell function with two independent glucose tolerance tests in fGDM women divided according to their glucose tolerance.

DESIGN AND PATIENTS

A total of 108 fGDM women divided into normal glucose tolerance (IGT; N = 82), impaired glucose metabolism (IGM; N = 20) and overt type 2 diabetes (T2DM; N = 6) groups, and 38 healthy control women (CNT) underwent intravenous (IVGTT) and oral glucose tolerance tests (OGTT). Measurements Insulin sensitivity and beta-cell function were assessed by both the IVGTT and the OGTT.

RESULTS

Both tests revealed impaired insulin sensitivity in the normotolerant group compared to controls (IVGTT: 4.2 +/- 0.3 vs. 5.4 +/- 0.4 10(-4) min(-1) (microU/ml)(-1); OGTT: 440 +/- 7 vs. 472 +/- 9 ml min(-1) m(-2)). Conversely, no difference was found in beta-cell function from the IVGTT. However, some parameters of beta-cell function by OGTT modelling analysis were found to be impaired: glucose sensitivity (106 +/- 5 vs. 124 +/- 7 pmol min(-1) m(-2) mm(-1), P = 0.0407) and insulin secretion at 5 mm glucose (168 +/- 9 vs. 206 +/- 10 pmol min(-1) m(-2), P = 0.003).

CONCLUSIONS

Both insulin sensitivity and beta-cell function are impaired in normotolerant fGDM but the subtle defect in beta-cell function is disclosed only by OGTT modelling analysis.

Metabolic syndrome at follow-up in women with and without gestational diabetes mellitus in index pregnancy

We prospectively studied 262 women with prior gestational diabetes mellitus (GDM) and 66 control women to compare their prevalence of metabolic syndrome and its relationship with insulin secretion and sensitivity. A 75-g oral glucose tolerance test was scheduled 5 years after delivery along with lipid profile, anthropometrics, and blood pressure measurement. Metabolic syndrome was defined according to the National Cholesterol Education Program 2001, and insulin sensitivity and secretion were estimated with the homeostasis model assessment. Women with prior GDM had similar insulin sensitivity and lower insulin secretion than control women. In comparison with control women, women with prior GDM had higher blood pressure, waist circumference, very low-density lipoprotein cholesterol, and oral glucose tolerance test blood glucose values but, with the exception of fasting hyperglycemia, did not have an increased prevalence of metabolic syndrome or its components. The multivariate prediction of metabolic syndrome and its components was similar with age and current homeostasis model assessment-insulin secretion and resistance indexes or with age, obesity, and GDM. The main predictor was current insulin resistance in the first case and obesity in the second, obesity being the best predictor overall. We conclude that in our population and at midterm follow-up, women with prior GDM have a decreased insulin secretion and display a higher prevalence of fasting hyperglycemia but not the full-blown picture of metabolic syndrome. Obesity, a surrogate index of insulin resistance, is the best predictor of metabolic syndrome at follow-up.

The prevalence of the metabolic syndrome in a danish population of women with previous gestational diabetes mellitus is three-fold higher than in the general population

CONTEXT

Diabetes and obesity, components of the metabolic syndrome, are common characteristics of women with prior gestational diabetes mellitus (GDM). Due to increasing incidence of diabetes and obesity, the metabolic syndrome might comprise a major health problem among these women.

OBJECTIVE

The objective was to estimate the prevalence of the metabolic syndrome by three different criteria [World Health Organization 1999 (WHO), The National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults 2001, and European Group for the Study of Insulin Resistance 2002] among women with previous GDM.

DESIGN

We conducted a follow-up study of a Danish cohort of women admitted in 1978-1996 to the Diabetes and Pregnancy Center, Rigshospitalet, Copenhagen University Hospital, with diet-treated GDM. The follow-up took place in 2000-2002 at median 9.8 yr (interquartile range 6.4-17.2) after pregnancy. Results were compared with a control group of 1000 age-matched women from a population-based sample (Inter99).

PARTICIPANTS

Four hundred eighty-one women at median age 43 yr (interquartile range 38-48) participated.

MAIN OUTCOME MEASURES

The main outcome measures were body mass index (BMI), glucose tolerance, blood pressure, lipid profile, and insulin resistance.

RESULTS

Independent of the criteria, the prevalence of the metabolic syndrome was three times higher in the prior GDM group, compared with the control group (e.g. WHO: 38.4 vs. 13.4%, P < 0.0005). Age- and BMI-adjusted odds ratio for having the WHO-defined metabolic syndrome was 3.4 (95% confidence interval 2.5-4.8) for the prior GDM group vs. the control group. Obese women (BMI > 30 kg/m(2)) with previous GDM had a more than 7-fold increased prevalence of the metabolic syndrome (WHO), compared with normal-weight prior GDM women (BMI < 25 kg/m(2)). In glucose-tolerant women, the prevalence was doubled in the prior GDM group, compared with control group.

CONCLUSION

The prevalence of the metabolic syndrome was three times as high in women with prior diet-treated GDM, compared with age-matched control subjects.

Gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is defined as glucose intolerance of various degrees that is first detected during pregnancy. GDM is detected through the screening of pregnant women for clinical risk factors and, among at-risk women, testing for abnormal glucose tolerance that is usually, but not invariably, mild and asymptomatic. GDM appears to result from the same broad spectrum of physiological and genetic abnormalities that characterize diabetes outside of pregnancy. Indeed, women with GDM are at high risk for having or developing diabetes when they are not pregnant. Thus, GDM provides a unique opportunity to study the early pathogenesis of diabetes and to develop interventions to prevent the disease.

Gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is defined as glucose intolerance of various degrees that is first detected during pregnancy. GDM is detected through the screening of pregnant women for clinical risk factors and, among at-risk women, testing for abnormal glucose tolerance that is usually, but not invariably, mild and asymptomatic. GDM appears to result from the same broad spectrum of physiological and genetic abnormalities that characterize diabetes outside of pregnancy. Indeed, women with GDM are at high risk for having or developing diabetes when they are not pregnant. Thus, GDM provides a unique opportunity to study the early pathogenesis of diabetes and to develop interventions to prevent the disease.

Studies of the Ala/Val98 polymorphism of the hepatocyte nuclear factor-1alpha gene and the relationship to beta-cell function during an OGTT in glucose-tolerant women with and without previous gestational diabetes mellitus

AIMS

In pregnancies complicated by gestational diabetes mellitus (GDM) an increased demand for insulin is not met due to beta-cell dysfunction. An Ala/Val polymorphism at codon 98 of the hepatocyte nuclear factor-1alpha (HNF-1alpha) gene has been associated with decreased serum insulin and C-peptide responses during an oral glucose tolerance test (OGTT) in glucose-tolerant subjects. The aims of the present study were to evaluate the influence of the polymorphism on the serum insulin and C-peptide responses to an OGTT in glucose-tolerant women with and without previous GDM and to investigate if this polymorphism is associated with GDM.

METHODS

The Ala/Val98 polymorphism was measured in 376 women of Danish origin with previous GDM, and in 724 age-matched and 310 middle-aged glucose tolerant women using polymerase chain reaction-restriction fragment length polymorphism.

RESULTS

The allelic frequency of the Ala/Val98 polymorphism was 0.043 [95% confidence interval (CI) 0.028, 0.057] in women with previous GDM vs. 0.037 (95% CI 0.028, 0.047) in age-matched and 0.039 (95% CI 0.024, 0.054) in middle-age women. Among 117 glucose-tolerant women with previous GDM, 10 carriers of the Ala/Val98 polymorphism had a non-significant 27% and 22% reduction in serum C-peptide and insulin levels, respectively, at 30 min during an OGTT. Seventy-eight control subjects carrying the Ala/Val98 polymorphism had a 10% (P = 0.001) and 16% (P = 0.004) reduction in serum C-peptide and insulin levels, respectively, compared with 956 Ala/Ala control subjects.

CONCLUSIONS

The Ala/Val polymorphism at codon98 of HNF-1alpha is not associated with GDM in Danish women. However, the codon 98 variant is associated with a significant impairment of serum insulin and C-peptide responses during an OGTT in glucose-tolerant women without previous GDM.

Liver-fat accumulation and insulin resistance in obese women with previous gestational diabetes

OBJECTIVE

We determined whether fat accumulation in the liver is associated with features of insulin resistance independent of obesity.

RESEARCH METHODS AND PROCEDURES

We recruited 27 obese nondiabetic women in whom liver fat (LFAT) content was determined by proton spectroscopy, intra-abdominal and subcutaneous fat by magnetic resonance imaging, and insulin sensitivity by the euglycemic insulin clamp technique. The women were divided based on their median LFAT content (5%) to groups with low (3.2 +/- 0.3%) and high (9.8 +/- 1.5%) liver fat. The groups were almost identical with respect to age (36 +/- 1 vs. 38 +/- 1 years in low vs. high-LFAT), body mass index (32.2 +/- 0.6 vs. 32.8 +/- 0.5 kg/m(2)), waist-to-hip ratio, intra-abdominal, subcutaneous, and total fat content.

RESULTS

Women with high LFAT had features of insulin resistance including higher fasting serum triglyceride (1.93 +/- 0.21 vs. 1.11 +/- 0.09 mM, p < 0.01) and insulin (14 +/- 3 vs. 10 +/- 1 mU/L, p < 0.05) concentrations than women with low LFAT. The group with high LFAT also had higher 24-hour blood pressures, and lower whole-body insulin sensitivity compared with the low-LFAT group.

DISCUSSION

In obese women with previous gestational diabetes, LFAT, rather than any measure of body composition, is associated with features of insulin resistance.

Postpartum care of the woman with diabetes

The postpartum period in women with diabetes or GDM allows both the physician and mother to relax from the intensive medical and obstetric management that has permitted, in most cases, a successful and joyous outcome. The role of the physician, however, must switch to a proactive and preventive mode to formulate a reproductive health plan for women with diabetes and GDM. The plan should be individualized to address glycemic management and surveillance, nutritional management, contraception prescription, future pregnancy planning, and lifestyle changes. Essential to the development of a reproductive health plan is the active participation of the patient, who through education gains an understanding of the far-reaching effects her active participation will have on her subsequent health and possibly on that of her future children.