A population-based cohort study of the relation between maternal birthweight and risk of gestational diabetes mellitus in four racial/ethnic groups

Pregnancy-Associated Diabetes Mellitus and Stillbirths by Race and Ethnicity among Hospitalized Pregnant Women in the United States

OBJECTIVES

Racial disparities in preexisting diabetes mellitus (PDM) and gestational diabetes mellitus (GDM) remain largely unexplored. We examined national PDM and GDM prevalence trends by race/ethnicity and the association between these conditions and fetal death.

METHODS

This was a retrospective cross-sectional analysis of 69,539,875 pregnancy-related hospitalizations from 2002 to 2017 including 674,040 women with PDM (1.0%) and 2,960,797 (4.3%) with GDM from the US Nationwide Inpatient Sample Survey. Joinpoint regression was used to evaluate trends in prevalence. Survey logistic regression was used to evaluate the association between exposures (PDM and GDM) and outcome.

RESULTS

Overall, the average annual increase in prevalence was 5.2% (95% confidence interval [CI] 4.2-6.2) for GDM and 1.0% (95% CI -0.1 to 2.0) for PDM, during the study period. Hispanic (average annual percentage change 5.3, 95% CI 3.6 - 7.1) and non-Hispanic Black (average annual percentage change 0.9, 95% CI 0.1 - 1.7) women had the highest average annual percentage increase in the prevalence of GDM and PDM, respectively. After adjustment, the odds of stillbirth were highest for Hispanic women with PDM (odds ratio 2.41, 95% CI 2.23-2.60) and decreased for women with GDM (odds ratio 0.51, 95% CI 0.50-0.53), irrespective of race/ethnicity.

CONCLUSIONS

PDM and GDM prevalence is increasing in the United States, with the highest average annual percentage changes seen among minority women. Furthermore, the reasons for the variation in the occurrence of stillbirths among mothers with PDM and GDM by race/ethnicity are not clear and warrant additional research.

Association between Maternal Birth Weight and Gestational Diabetes Mellitus: A Systematic Review and Meta-Analysis

Background and Aims

Gestational diabetes mellitus is one of the most important issue related to health status of mothers and their children throughout life. This meta-analysis has been conducted to assess relationship between maternal birth weight and gestational diabetes.

Methods and Results

This article is written using PRISMA guideline for systematic review and meta-analysis. We searched epidemiological studies without a time limit from following databases-Scopus, PubMed, Science Direct, Embase, Web of Science, CINAHL, Cochrane, EBSCO, and Google Scholar search engine using MESH keywords. Heterogeneity was determined using the Cochran Q test and I ² index. Data were analyzed using comprehensive meta-analysis, version 2. The significance level of the tests was considered as P < 0.05.

Results

The result of combining ten studies with a sample size of 228,409 cases using a fixed-effect model showed that low maternal birth weight increased the risk of gestational diabetes mellitus (1.71 [95% CI 1.43-2.06, P < 0.001]). In addition, the result of combining nine studies with a sample size of 227,805 cases using a random-effects model showed that macrosomia did not increase the risk of gestational diabetes mellitus, and there was no significant relationship between them (1.04 [95% CI 0.79-1.38; p value: 0.730]).

Conclusion

The results of this systematic review and meta-analysis showed that low maternal birth weight could be a risk factor for gestational diabetes in adulthood.

Intergenerational associations of adverse birth outcomes: A surveillance report

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A statewide assessment of intergenerational adverse birth outcomes in terms of preterm birth and low birth weight.

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Associating both mother and her siblings' birth records to the adverse birth outcomes.

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Found significant intergenerational associations of adverse birth outcomes.

Nebraska births between 1995 and 2005 were followed until 2018 to look for intergenerational associations of low birth weight (LBW) and preterm birth (PTB). Results from generalized estimating equations revealed that mothers born LBW preterm were more likely to deliver LBW (adjusted OR 1.94, 95% CI 1.39–2.71) or preterm (adjusted OR 1.65, 95% CI 1.20–2.27) than mothers born with normal weight or at term. In addition, mothers who had an LBW sibling were 44% more likely to have an LBW infant (OR 1.44, 95% CI 1.04–2.00). A consistent finding was also observed for mothers who had a PTB sibling (OR 1.47, 95% CI 1.10–1.95). Mothers who were LBW at birth or had any LBW siblings, especially two or more siblings, were more likely to repeat this adverse birth outcome. The same association was also observed in mothers who were born preterm.

Influence of Acculturation on Risk for Gestational Diabetes Among Asian Women

Introduction

Asian women have a higher prevalence of gestational diabetes mellitus than women of other races/ethnicities. We aimed to compare the prevalence of gestational diabetes among Asian American women to other racial/ethnic groups and explore whether the higher occurrence of the disorder among Asian women can be explained by acculturation.

Methods

We conducted a population-based, cross-sectional study among 5,562 women who participated in the 2007 Los Angeles Mommy and Baby Study (LAMB) in Los Angeles County, California. All women included in this study had a live delivery in 2007 and did not have pre-pregnancy type I or II diabetes. We applied multivariate, weighted logistic regressions to compare gestational diabetes prevalence among racial/ethnic groups, adjusting for its known risk factors. We conducted mediation analysis to test whether the difference in prevalence across racial/ethnic groups could be explained by acculturation.

Results

Among the 5,562 women studied, the weighted prevalence of gestational diabetes was 15.5% among Asian American women, followed by 9.0% among non-Hispanic black women, 10.7% among Hispanic women, and 7.9% among non-Hispanic white women. Compared with non-Hispanic white women, Asian women had 2.44 (95% confidence interval [CI], 1.81–3.29; P < .001) times the odds of having gestational diabetes, independent of maternal age, education, marital status, income, prenatal care adequacy, prepregnancy BMI, and physical activity. Acculturation was negatively associated with having gestational diabetes (odds ratio [OR] = 0.93; 95% CI, 0.86–0.99) and explained 15.9% (95% CI, 11.38%–25.08%; P < .001) of the association between Asian race and the condition.

Conclusion

We found that Asian race was an independent risk factor for gestational diabetes, and higher acculturation may play a protective role against it in Asian American women.

Body surface area at birth and later risk for gestational diabetes mellitus among primiparous women

AIMS

To assess the relationship between body surface area (BSA) at birth and future risk for gestational diabetes mellitus (GDM).

METHODS

This is an observational cohort study from Vantaa, Finland. The cohort included 1548 Finnish primiparous women, aged 15-28 years, without pre-existing diabetes, who gave birth 2009-2015. All women were born full-term and had complete information about their birth weight and length, from the Finnish Medical Birth Register. Additional data for the study were provided by individual patient health records and Statistics Finland. Study participants were divided into five levels (I-V) according to BSA at birth, based on normal distribution.

RESULTS

There was an inverse association between BSA at birth and risk for GDM (p = 0.015 for linearity, after adjustments for age, educational attainment, pre-pregnancy BMI and smoking). The odds ratio (OR) for GDM in level V, with the largest BSA at birth, compared with level I, with the smallest BSA at birth, was 0.43 [95% confidence interval (CI) 0.22-0.83]; adjusted for age, educational attainment, pre-pregnancy body mass index and smoking. The OR for GDM was 0.8 (95% CI 0.68-0.95, p = 0.009) for each one standard deviation increase in BSA at birth, adjusted for the same confounders. BSA at birth correlated with adult anthropometry: correlation coefficients were r = 0.16 (95% CI 0.11-0.21) for weight, r = 0.31 (95% CI 0.26-0.35) for height, and r = 0.06 (95% CI 0.01-0.11) for BMI.

CONCLUSIONS

Body surface area at birth is inversely associated with future risk for GDM in primiparous women.

Specific Metabolic Characteristics of Women With Former Gestational Diabetes: the Importance of Adipose Tissue

Women with a positive history of gestational diabetes mellitus (GDM) face a higher risk of developing type 2 diabetes mellitus (T2DM) and metabolic syndrome later in life. The higher risk of these metabolic complications is closely associated with adipose tissue. In this review, the importance of adipose tissue is discussed in relation to GDM, focusing on both the quantity of fat deposits and the metabolic activity of adipose tissue in particular periods of life: neonatal age, childhood, adolescence, and pregnancy followed by nursing. Preventive measures based on body composition and lifestyle habits with special attention to the beneficial effects of breastfeeding are also discussed.

High Prevalence of Gestational Diabetes Mellitus in Beijing: Effect of Maternal Birth Weight and Other Risk Factors

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with both short- and long-term adverse health consequences for both the mother and her offspring. The aim was to study the prevalence and risk factors for GDM in Beijing.

METHODS

The study population consisted of 15,194 pregnant women attending prenatal care in 15 hospitals in Beijing, who delivered between June 20, 2013, and November 30, 2013, after 28 weeks of gestation. The participants were selected by cluster sampling from the 15 hospitals identified through random systematic sampling based on the number of deliveries in 2012. A questionnaire was designed to collect information.

RESULTS

A total of 2987 (19.7%) women were diagnosed with GDM and 208 (1.4%) had diabetes in pregnancy (DIP). Age (OR: 1.053, 95% CI: 1.033-1.074, P < 0.01), family history of diabetes mellitus (OR: 1.481, 95% CI: 1.254-1.748, P < 0.01), prepregnancy body mass index (BMI) (OR: 1.481, 95% CI: 1.254-1.748, P < 0.01), BMI gain before 24 weeks (OR: 1.126, 95% CI: 1.075-1.800, P < 0.01), maternal birth weight (P < 0.01), and fasting plasma glucose at the first prenatal visit (P < 0.01) were identified as risk factors for GDM. In women with birth weight <3000 g, GDM rate was significantly higher.

CONCLUSIONS

One out of every five pregnant women in Beijing either had GDM or DIP and this constitutes a huge health burden for health services. Prepregnancy BMI and weight gain before 24th week are important modifiable risk factors for GDM. Ensuring birth weight above 3000 g may help reduce risk for future GDM among female offsprings.

Obesity, Diabetes, and Birth Outcomes Among American Indians and Alaska Natives

Objectives To examine the relationships between prepregnancy diabetes mellitus (DM), gestational diabetes mellitus (GDM), and prepregnancy body mass index, with several adverse birth outcomes: preterm delivery (PTB), low birthweight (LBW), and macrosomia, comparing American Indians and Alaska Natives (AI/AN) with other race/ethnic groups. Methods The sample includes 5,193,386 singleton US first births from 2009-2013. Logistic regression is used to calculate adjusted odds ratios controlling for calendar year, maternal age, education, marital status, Kotelchuck prenatal care index, and child's sex. Results AI/AN have higher rates of diabetes than all other groups, and higher rates of overweight and obesity than whites or Hispanics. Neither overweight nor obesity predict PTB for AI/AN, in contrast to other groups, while diabetes predicts increased odds of PTB for all groups. Being overweight predicts reduced odds of LBW for all groups, but obesity is not predictive of LBW for AI/AN. Diabetes status also does not predict LBW for AI/AN; for other groups, LBW is more likely for women with DM or GDM. Overweight, obesity, DM, and GDM all predict higher odds of macrosomia for all race/ethnic groups. Conclusions for Practice Controlling diabetes in pregnancy, as well as prepregnancy weight gain, may help decrease preterm birth and macrosomia among AI/AN.

The relation of a woman’s impaired in utero growth and association of diabetes during pregnancy

Small for gestational age (weight for gestational age <10th percentile, SGA) birth status and adulthood susceptibility to diabetes is well established, but the relationship to diabetes during pregnancy is incompletely understood. The authors investigated the association between women's impaired fetal growth (as measured by SGA status) and diabetes mellitus (DM) during pregnancy. Stratified and multivariable binomial regression analyses were performed on the Illinois transgenerational dataset. Former SGA (n = 13,934) mothers had a greater prevalence of DM during pregnancy than former appropriate for gestational age (AGA) mothers (n = 116,683): 2.7 versus 1.9 %, relative prevalence (RP) equaled 1.4 [95 % confidence interval (CI)1.3, 1.6]. In a multivariable binomial regression model, the adjusted RP (95 %CI) (controlling for maternal age, education, parity, plurality, marital status, and race/ethnicity) for DM during pregnancy for former SGA (compared to AGA) mothers equaled 1.5 (1.3, 1.6). When stratified by race/ethnicity, the adjusted RP (95 % CI) of DM during pregnancy for former SGA (compared to AGA), non-Latina White, African-American, and Mexican-American mothers was 1.4 (1.3, 1.6), 1.6 (1.2, 2.1), and 2.3 (1.1, 4.7), respectively. The authors conclude that impaired fetal growth (as measured by SGA status) is a risk factor for DM during pregnancy among the leading racial/ethnic groups in the United States.

Diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand and the United States

Recently proposed international guidelines for screening for gestational diabetes mellitus (GDM) recommend additional screening in early pregnancy for sub-populations at a high risk of type 2 diabetes mellitus (T2DM), such as indigenous women. However, there are criteria that should be met to ensure the benefits outweigh the risks of population-based screening. This review examines the published evidence for early screening for indigenous women as related to these criteria. Any publications were included that referred to diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand and the United States (n = 145). The risk of bias was appraised. There is sufficient evidence describing the epidemiology of diabetes in pregnancy, demonstrating that it imposes a significant disease burden on indigenous women and their infants at birth and across the lifecourse (n = 120 studies). Women with pre-existing T2DM have a higher risk than women who develop GDM during pregnancy. However, there was insufficient evidence to address the remaining five criteria, including the following: understanding current screening practice and rates (n = 7); acceptability of GDM screening (n = 0); efficacy and cost of screening for GDM (n = 3); availability of effective treatment after diagnosis (n = 6); and effective systems for follow-up after pregnancy (n = 5). Given the impact of diabetes in pregnancy, particularly undiagnosed T2DM, GDM screening in early pregnancy offers potential benefits for indigenous women. However, researchers, policy makers and clinicians must work together with communities to develop effective strategies for implementation and minimizing the potential risks. Evidence of effective strategies for primary prevention, GDM treatment and follow-up after pregnancy are urgently needed.

Early life influences on cardio-metabolic disease risk in aboriginal populations--what is the evidence? A systematic review of longitudinal and case-control studies

BACKGROUND

We systematically reviewed the published evidence for the developmental origins of health and disease hypothesis among aboriginal populations from Australia, Canada, New Zealand and the USA.

METHODS

Medline, EMBASE and the Informit Health databases were systematically searched (March 2012) using medical subject headings and keywords for studies that examined the effect of prenatal factors and birth outcomes on later life (≥3 years) cardio-metabolic diseases. Quality of studies was independently assessed by two reviewers using a risk of bias assessment tool; main findings from studies with a low to moderate risk of bias were summarised qualitatively.

RESULTS

In all, 844 studies were found; 50 were included in the review of which 41 had a low-moderate risk of bias. There was strong evidence for an association between birth weight and type 2 diabetes (6/7 studies), impaired kidney function (6/7 studies) and high blood pressure (5/6 studies), whereas there was limited evidence for an association with metabolic abnormalities (4/7 studies) and adiposity (4/7). Exposure to maternal diabetes was strongly associated with type 2 diabetes (9/10 studies) and metabolic abnormalities (5/7 studies), whereas the association with adiposity was low (3/9 studies); the limited number of studies, to date, also show a relationship with high blood pressure (2/2 studies).

CONCLUSIONS

This review highlights that interventions to reduce the burden of cardio-metabolic disease among aboriginal populations should focus on improving maternal health, particularly by reducing the prevalence of diabetes in pregnancy. Future research should also be directed towards potential protective actions, such as breastfeeding.

Women born preterm or with inappropriate weight for gestational age are at risk of subsequent gestational diabetes and pre-eclampsia

Introduction

Low birthweight, which can be caused by inappropriate intrauterine growth or prematurity, is associated with development of gestational diabetes mellitus (GDM) as well as pre-eclampsia later in life, but the relative effects of prematurity and inappropriate intrauterine growth remain uncertain.

Methods

Through nation-wide registries we identified all Danish mothers in the years 1989–2007. Two separate cohorts consisting mothers born 1974–1977 (n = 84219) and 1978–1981 (n = 32376) were studied, due to different methods of registering birthweight and gestational age in the two periods. Data was linked with information on GDM, pre-eclampsia and education.

Results

In a multivariate logistic regression model the odds of developing GDM was increased by 5–7% for each week the mother was born before term (p = 0.018 for 1974–1977, p = 0.048 for 1978–1981), while the odds were increased by 13–17% for each standard deviation (SD) reduction in birthweight for gestational age for those who were small or normal for gestational age (p<0.0001 and p = 0.035) and increased by 118–122% for each SD increase above the normal range (p<0.0001 and p = 0.024). The odds of pre-eclampsia was increased by 3–5% for each week the mother was born before term (p = 0.064 and p = 0.04), while the odds were increased 11–12% for each SD reduction in birthweight for gestational age (p<0.0001 and p = 0.0002).

Conclusion

In this cohort of young Danish mothers, being born premature or with increasingly low birthweight for gestational age was associated with an increased risk of GDM and pre-eclampsia in adulthood, while increasingly high birthweight for gestational age was associated with an increased risk of GDM and a decreased risk of pre-eclampsia. Inappropriate weight for gestational age was a more important risk factor than prematurity.

Age at menarche, menstrual characteristics, and risk of preeclampsia

We examined associations of age at menarche and menstrual characteristics with the risk of preeclampsia among participants (n = 3,365) of a pregnancy cohort study. Data were collected using in-person interviews and medical record abstraction. Logistic regression was used to estimate adjusted odds ratio (OR) and 95% confidence interval (95% CI). There was a significant inverse association between age at menarche and risk of preeclampsia (P value for trend < 0.05). Association of long cycle length (>36 days) with higher risk of preeclampsia was present only among women who had prepregnancy body mass index <25 kg/m(2) (interaction P value = 0.04). Early menarche is associated with higher risk of preeclampsia. Prepregnancy weight may modify associations of long menstrual cycles with risk of preeclampsia.

Increasing incidence of gestational diabetes mellitus in Louisiana, 1997-2009

BACKGROUND

Gestational diabetes mellitus (GDM) is one of the most common pregnancy complications. Although long-term trends are available at the national level, they are less clear for population subgroups, especially those with middle or low income and also at high risk of obesity.

METHOD

We conducted a retrospective study among women aged 15-50 years with live deliveries between January 1, 1997, and December 31, 2009, at the Louisiana State University Health Care Services Division hospital system. Pregnancies and GDM cases were identified by using ICD-9 code from the Louisiana State University Hospital-Based Longitudinal Study database. The annual incidence of GDM and its standard error (SE) were calculated and stratified by age group and race.

RESULTS

A total of 2751 GDM incident cases were identified among 62,685 pregnancies between 1997 and 2009. The crude incidence of GDM increased from 4.1% in 1997 to 4.4% in 2009 (increased by 7.3%), and the age-standardized incidence of GDM increased from 5.8% to 7.5% (increased by 29.3%). The incidence of GDM increased with age and reached a peak at 35-39 years of age and then declined in women who were 40-50 years old. Among the three studied races, Asians had significantly higher incidence of GDM than whites and African Americans.

CONCLUSIONS

The incidence of GDM increased in most years from 1997 to 2009 and reached a peak in 2002 in the women served by Louisiana State University Health Care Services Division hospitals. GDM has become an important public health problem, particularly among women aged 35-39 years.

Definition, epidemiology, risk factors

Gestational diabetes mellitus is defined as glucose intolerance that begins or is first recognized during pregnancy. Its prevalence, generally situated between 2-6%, may reach 10-20% in high-risk populations, with an increasing trend across most racial/ethnic groups studied. Among traditional risk factors, previous gestational diabetes, advanced maternal age and obesity have the highest impact on gestational diabetes risk. Racial/ethnic origin and family history of type 2 diabetes have a significant but moderate impact (except for type 2 diabetes in siblings). Several non traditional factors have been recently characterized, either physiological (low birthweight and short maternal height) or pathological (polycystic ovaries). The multiplicity of risk factors and their interactions results in a low reliability of risk prediction on an individual basis.

Early life nutrition and metabolic programming

Research investigating the early programming of adult metabolic disease has in recent years provided much mechanistic insight into how the early environment impacts on long-term health. It includes studies addressing the roles of intrauterine nutrient availability, which is determined by maternal nutrition, maternal exposure to oxygen, toxic events, and infection; the placental interface; and also the early postnatal environment. This review will explore the epidemiological evidence for programming of metabolic disease and provide an overview of the various studies using animals to model metabolic phenotypic outcome. It will also discuss evidence for the proposed molecular mechanisms and the potential for intervention.

Non classical risk factors for gestational diabetes mellitus: a systematic review of the literature

Age, obesity and family history of diabetes are well known risk factors for gestational diabetes mellitus. Others are more controversial. The objective of this review is to find evidence in the literature that justifies the inclusion of these other conditions among risk factors. The MEDLINE, Cochrane, LILACS and Pan American Health Organization databases were searched, covering articles dating from between 1992 and 2006. Keywords were used in combination (AND) with gestational diabetes mellitus separately and with each one of the risk factors studied. The methodological quality of the studies included was assessed, resulting in the selection of 41 papers. Most studies investigating maternal history of low birth weight, low stature, and low level of physical activity have found positive associations with gestational diabetes mellitus. Low socioeconomic levels, smoking during pregnancy, high parity, belonging to minority groups, and excessive weight gain during pregnancy presented conflicting results. Publication bias cannot be ruled out. Standardization of techniques, cutoff points for screening and diagnosis, as well as studies involving larger sample sizes would allow future meta-analyses.

The Illinois transgenerational birth file: life-course analysis of birth outcomes using vital records and census data over decades

We endeavored to construct a transgenerational birth file (TGBF) for use in longitudinal research on perinatal outcomes; such a file should contain social context data for women at the time of their own birth and the birth of their offspring. Births in Illinois from 1989 to 1991 were linked to the birth records of their mothers (and when possible, their fathers) born in Illinois between 1956 and 1976 (N = 267,303), on the basis of each parent's complete name and exact date of birth. Mortality data (survival or death) were then linked to each transgenerational record. Neighborhood median family income from census files was merged by geographic code to records from the Chicago area. An infant-mother match rate of 78% was achieved, and about half of these paired records could also be matched to fathers. For Chicago area births (N = 97,755), linkage to census data was also completed for nearly 100% of records, allowing us to characterize the economic situation of the mother at the time of her birth as well as when she had her own baby. Analysis of the TGBF showed a slight bias toward more educated parents compared to the total state population, especially the subset with successful match to both parents. The infant mortality, LBW, and VLBW rates in the TGBF population differed little from the overall rates for Illinois. This project demonstrates the feasibility of creating a data set for studying outcomes of childbearing women within a lifetime social and economic context in a US population. Despite some bias in exclusion of less educated parents, mortality and LBW rates suggest that the TGBF is fairly representative with regard to important infant health outcomes.

Physical activity and gestational diabetes mellitus among Hispanic women

OBJECTIVE

Studies in predominantly non-Hispanic white populations have suggested that physical activity during pregnancy is associated with a reduced risk of gestational diabetes mellitus (GDM). There are few such studies in Hispanic women, a group at increased risk for GDM.

METHODS

We conducted a prospective cohort study of household/caregiving, occupational, sports/exercise, and active living habits and the risk of GDM among 1006 Hispanic (predominantly Puerto Rican) prenatal care patients in western Massachusetts from 2000 to 2004. Prepregnancy, early pregnancy, and midpregnancy physical activity was assessed using the Kaiser Physical Activity Survey.

RESULTS

A total of 33 women (3.3%) were diagnosed with GDM, and 119 women (11.8%) were diagnosed with abnormal glucose tolerance. There were no significant associations between GDM risk and occupational and active living activities in prepregnancy, early pregnancy, and midpregnancy or with a change in levels of household/caregiving, occupational, and active living activities from prepregnancy to during pregnancy. However, after controlling for age and prepregnancy body mass index (BMI), women in the highest quartile of prepregnancy (OR = 0.2, 95% CI 0.1-0.8, p(trend) = 0.03) and midpregnancy (OR = 0.2, 95% CI 0.1-0.8, p(trend) = 0.004) household/caregiving activities as well as midpregnancy sports/exercise (0.1, 95% CI 0.0-0.7, p(trend) = 0.12) had a reduced risk of GDM compared with women in the lowest quartile.

CONCLUSIONS

Findings in this Hispanic population, although based on small numbers of cases, are consistent with prior research among predominantly non-Hispanic white populations.

The increasing prevalence of diabetes in pregnancy

The authors review studies published in the past 10 years that examine the prevalence and trends in the prevalence of gestational diabetes mellitus (GDM). The prevalence of GDM in a population is reflective of the prevalence of type 2 diabetes within that population. In low-risk populations, such as those found in Sweden, the prevalence in population-based studies is lower than 2% even when universal testing is offered, whereas studies in high-risk populations, such as the Native American Cree, Northern Californian Hispanics, and Northern Californian Asians, reported prevalence rates ranging from 4.9% to 12.8%. Prevalence rates for GDM obtained from hospital-based studies similarly reflect the risk of type 2 diabetes in a population with a single hospital-based study in Australia reporting prevalences ranging from 3.0% in Anglo-Celtic women to 17.0% in Indian women. Finally, of the eight studies published that report on trends in the prevalence of GDM, six report an increase in the prevalence of GDM across most racial/ethnic groups studied. In summary, diabetes during pregnancy is a common and increasing complication of pregnancy.

Racial and ethnic variation in access to health care, provision of health care services, and ratings of health among women with histories of gestational diabetes mellitus

OBJECTIVE

The purpose of this study was to assess racial/ethnic variation in access to health care, use of particular health care services, presence of cardiovascular risk factors, and perceptions of health and impairment among women at risk for type 2 diabetes because of their histories of gestational diabetes mellitus (hGDM).

RESEARCH DESIGN AND METHODS

We performed a cross-sectional study using the 2001-2003 Behavioral Risk Factor Surveillance System, a national population-based, random sample telephone survey. We assessed access to health care, use of family planning, measurement and elevation of cholesterol, elevation of blood pressure, and respondents' perceptions of health and impairment among women aged 18-44 years with hGDM (n = 4,718). Multivariate models adjusted for sociodemographic characteristics, BMI, presence of children in the household, and current smoking.

RESULTS

Outcome measures were suboptimal across racial/ethnic groups. Approximately one-fifth of the overall population reported no health insurance, cost barriers to physician visits, and no primary care provider. One-quarter had no examination within the past year, and almost one-fifth reported no family planning and elevated cholesterol levels. Latinas were the most disadvantaged, with 40% reporting no health insurance and no primary care provider and one-fourth reporting suboptimal perceptions of health. Asian/Pacific Islanders were the most advantaged in terms of health care access, cholesterol and blood pressure elevation, and impaired physical health. Racial/ethnic differences in health care use and presence of risk factors were not entirely explained by health care access or other covariates.

CONCLUSIONS

Significant racial/ethnic variation exists among women with hGDM for access to and use of health care, presence of risk factors, and perceptions of health.

The increasing prevalence of diabetes in pregnancy

The authors review studies published in the past 10 years that examine the prevalence and trends in the prevalence of gestational diabetes mellitus (GDM). The prevalence of GDM in a population is reflective of the prevalence of type 2 diabetes within that population. In low-risk populations, such as those found in Sweden, the prevalence in population-based studies is lower than 2% even when universal testing is offered, whereas studies in high-risk populations, such as the Native American Cree, Northern Californian Hispanics, and Northern Californian Asians, reported prevalence rates ranging from 4.9% to 12.8%. Prevalence rates for GDM obtained from hospital-based studies similarly reflect the risk of type 2 diabetes in a population with a single hospital-based study in Australia reporting prevalences ranging from 3.0% in Anglo-Celtic women to 17.0% in Indian women. Finally, of the eight studies published that report on trends in the prevalence of GDM, six report an increase in the prevalence of GDM across most racial/ethnic groups studied. In summary, diabetes during pregnancy is a common and increasing complication of pregnancy.

Mechanisms by which poor early growth programs type-2 diabetes, obesity and the metabolic syndrome

Fetal programming is gaining momentum as a highly documented phenomenon which links poor early growth to adult disease. It is backed up by large cohorts in epidemiological studies worldwide and has been tested in various animal models. The root causes of programming link closely with maternal condition during pregnancy, and therefore the fetal environment. Suboptimal fetal environments due to poor or inadequate nutrition, infection, anemia, hypertension, inflammation, gestational diabetes or hypoxia in the mother expose the fetus to hormonal, growth factor, cytokine or adipokine cues. These in turn act to alter metabolic, immune system, vascular, hemodynamics, renal, growth and mitochondrial parameters respectively and most evidently in the later stages of life where they impact on the individual as poor glucose homeostasis, insulin resistance, type 2 diabetes, hypertension, cardiovascular disease, obesity and heart disease. These events are compounded by over-nutrition or lifestyle choices which are in conflict with the programming of the fetus. We and others have utilised various species to test the early life programming hypothesis and to identify key molecular mechanisms. With parallel studies of human cohorts, these molecular markers can be validated as realistic targets for intervention.

Developmental origins of the metabolic syndrome: prediction, plasticity, and programming

The "fetal" or "early" origins of adult disease hypothesis was originally put forward by David Barker and colleagues and stated that environmental factors, particularly nutrition, act in early life to program the risks for adverse health outcomes in adult life. This hypothesis has been supported by a worldwide series of epidemiological studies that have provided evidence for the association between the perturbation of the early nutritional environment and the major risk factors (hypertension, insulin resistance, and obesity) for cardiovascular disease, diabetes, and the metabolic syndrome in adult life. It is also clear from experimental studies that a range of molecular, cellular, metabolic, neuroendocrine, and physiological adaptations to changes in the early nutritional environment result in a permanent alteration of the developmental pattern of cellular proliferation and differentiation in key tissue and organ systems that result in pathological consequences in adult life. This review focuses on those experimental studies that have investigated the critical windows during which perturbations of the intrauterine environment have major effects, the nature of the epigenetic, structural, and functional adaptive responses which result in a permanent programming of cardiovascular and metabolic function, and the role of the interaction between the pre- and postnatal environment in determining final health outcomes.

Intra-uterine transmission of disease

Fetal development is dependent on maternal supply of fuels and building blocks. Disturbed maternal metabolism or inappropriate maternal nutrition confronts the fetus with an unfavourable intra-uterine milieu. Structural and functional adaptations occur during development and maturation of organs. Consequences of these fetal alterations persist postnatally and may result in metabolic alterations throughout life. Gestational diabetes can occur in these offspring and transmit the effect to the next generation. These alterations in fetal development can be associated with fetal macrosomia (maternal diabetes) or fetal growth-restriction (maternal/fetal malnutrition). The relation between birth weight and later metabolic disease therefore is U-shaped. Adult metabolic condition is thus to a considerable extent programmed in utero, fetal and neonatal weight being symptoms of disturbed fetal development. This concept of intra-uterine programming of disease is illustrated with a review of epidemiological human studies and experimental animal studies.

The association of grandmaternal and maternal factors with maternal adult stature

BACKGROUND

Stature is an important determinant of several reproductive and non-reproductive health problems. Documentation of secular trends in stature has been based primarily on cross-sectional studies of special populations, primarily of men. The objective of this study is to determine how growth and socio-economic status (SES) factors relate to stature changes among lineal female relatives, maternal grandmothers to mothers.

METHODS

The study base was derived from a population-based intergenerational cohort which linked several statewide databases to data from the mothers' own birth certificates: the Washington State Intergenerational Cohort. Mothers in these ethnic groups were separately studied: non-Hispanic Whites, African Americans, Native Americans, Hispanics. We generated simple, partial, and multiple correlation coefficients to investigate the association between stature and other growth and SES factors.

RESULTS

A mother's stature is determined partly by her own mother's stature and partly by her birthweight. These two measures are individually stronger predictors of stature than are several available SES factors considered in combination-grandmother's age, parity, marital status, and mother's age. The maximal multiple correlation models yielded R2 values from 18% to 28%.

CONCLUSIONS

Growth measures are stronger predictors of intergenerational changes in stature than are the several available socio-economic factors. However, socio-economic factors are partly responsible for the level of achieved prenatal and postnatal growth. Since grandmother's stature is a determinant of mother's birthweight, which in turn is a determinant of infant birthweight, some environmentally influenced determinants of some birth outcomes are already established before a prospective mother is conceived or born.

The association of maternal growth and socio-economic measures with infant birthweight in four ethnic groups

BACKGROUND

Both maternal socio-economic status (SES) and growth measures are themselves interrelated and are also related to infant birthweight. The objective of this study is to compare the relative importance of such maternal measures as determinants of birthweight of female infants-the prospective mothers of the next generation.

METHODS

The study base was derived from a population-based multiethnic intergenerational cohort: the Washington State Intergenerational Cohort. Infants of mothers from four ethnic groups were included: non-Hispanic Whites, African Americans, Native Americans, and Hispanics. We generated simple, partial, and multiple correlation coefficients to investigate the association between birthweight and the maternal growth and SES measures.

RESULTS

While there were slight differences among the ethnic groups, generally each of three maternal pre-conceptional growth measures-birthweight, stature, and pre-pregnant weight-was a stronger predictor of female infant birthweight than were each of the five maternal SES factors-age, parity, marital status, educational attainment, and prenatal care onset. After accounting for the proportion of variation in birthweight explained by the maternal growth measures and maternal smoking, the addition of the five SES variables added relatively little to the prediction of infant birthweight. The maximal multiple correlation coefficients (R2) yield values ranging from 9.5% to 12.8%.

CONCLUSIONS

A mother's growth before pregnancy is a stronger predictor of infant birthweight than is her current socio-economic circumstance. Since the mother's growth must have been influenced by the socio-economic circumstances of her family of upbringing, this further highlights the intergenerational contribution on a woman's reproductive success.

Plasma AA and DHA levels are not compromised in newly diagnosed gestational diabetic women

OBJECTIVE

The polyunsaturated fatty acids, arachidonic (AA) and docosahexaenoic (DHA), are vital structural and functional components of the neural, vascular and visual systems. There is increased demand for these fatty acids during pregnancy. Diabetes impairs the synthesis of both AA and DHA. We have investigated the possibility that pregnancy-induced diabetes compromises the levels of plasma AA and DHA in newly diagnosed expectant mothers.

DESIGN

Cross-sectional study.

SETTING

London, UK.

SUBJECTS AND METHODS

Venous blood was obtained from 44 women with gestational diabetes mellitus (GDM) and from the same number of nondiabetics, during the third trimester. Fatty acid composition of plasma choline phosphoglycerides (CPG), triglycerides (TG) and cholesterol esters (CE) was analysed.

RESULTS

The GDM women had higher levels of AA (20:4n-6; P<0.0001) and AA/linoleic acid ratio (20:4n-6/18:2n-6; P<0.01) in the CPG, and linoleic acid (LA; P<0.0001), total n-6 (P<0.01), DHA (P<0.05) and n-3 metabolites (P<0.05) in TG compared to their nondiabetic counterparts. Similarly, AA (P<0.0001), osbond acid (22:5n-6; P<0.05), total n-6 metabolites (P<0.0001), AA/LA (P<0.0001) and n-6 metabolites/LA (P<0.01) were higher in the CE of the GDM women. There was no difference in the levels of DHA in CPG and CE between the two groups (P>0.05).

CONCLUSIONS

The results of this study do not provide evidence that the activity of delta-6 or delta-5 desaturases, which are vital for the synthesis of AA and DHA, is compromised by pregnancy-induced diabetes. However, since the samples were taken at diagnosis, it is conceivable that the duration of the diabetes was too short to have a discernable adverse effect on the levels of AA and DHA in plasma lipids.

Maternal birth weight in relation to plasma lipid concentrations in early pregnancy

OBJECTIVE

The purpose of this study was to determine the extent to which, if at all, maternal weight at birth is related to dyslipidemia during early pregnancy, which is a risk factor for preeclampsia.

STUDY DESIGN

This hospital-based prospective cohort study included 1000 women who initiated prenatal care before 16 weeks of gestation. Participants provided information about their birth weight and other sociodemographic and reproductive covariates. Plasma triglyceride, high-density lipoprotein cholesterol, and total cholesterol concentrations were measured at approximately 13 weeks of gestation. beta coefficients and standard errors were estimated by multiple linear regression; odds ratios and 95% confidence intervals were estimated by logistic regression.

RESULTS

Maternal birth weight was correlated negatively with triglycerides (r =-0.12; P =.001) and was correlated positively with high-density lipoprotein cholesterol (r =0.08; p =.02) but not statistically significantly related with total cholesterol (r =-0.004; P=.91). After adjusting for potential confounders, women who weighed <2500 g at birth had higher triglyceride and total cholesterol concentrations (beta=23.4 mg/dL [P<.001]; beta =2.6 mg/dL [P =.585], respectively) and lower high-density lipoprotein cholesterol concentrations (beta =-3.2 mg/dL; P=.105), when compared with women who weighed 3000 to 3499 g at birth. Women who were born small (<2500 g) and became overweight (body mass index, >or=25 kg/m(2)) in adulthood had less favorable lipid profiles than their counterparts who weighed >or=2500 g at birth and remained lean (body mass index, <25 kg/m(2)).

CONCLUSION

Our findings suggest that factors that are related to growth in utero may help to predict the subsequent risk of altered lipid metabolism during pregnancy, which may, in turn, be causally related to the occurrence of preeclampsia.

Weight at birth and subsequent risk of preeclampsia as an adult

OBJECTIVE

We examined the influence of maternal birth weight on the risk of the development of preeclampsia, a likely precursor to adult chronic disease.

STUDY DESIGN

This hospital-based case-control study included 181 preeclampsia cases and 349 control subjects. Participants provided information about their birth weight and other covariates that included medical and reproductive history, prepregnancy weight, and adult height. Odds ratios and 95% CIs were estimated by logistic regression.

RESULTS

The risk of preeclampsia decreased as maternal birth weight increased (P=.01). After an adjustment was made for confounders, data showed that women with a low birth weight (<2500 g) had a 2.3-fold increased risk of experiencing preeclampsia (95% CI, 1.0-5.3) as compared with women who weighed 2500 to 2999 g at birth. Conversely, women with a birth weight of >/=4000 g appeared to have a nonstatistically significant, but >50%, reduction in the risk of experiencing preeclampsia (95% CI, 0.2-1.2). This relationship differed for lean and overweight women (body mass index, <25 kg/m(2) vs >/=25 kg/m(2)). Among lean women, those who were low birth weight had a near doubling in risk of the development of preeclampsia (odds ratio, 1.9; 95% CI, 0.8-4.6), although this association did not reach statistical significance. However, among overweight women, those women who weighed <2500 g at birth had an almost 4-fold increased risk of experiencing preeclampsia (odds ratio, 3.8; 95% CI, 1.1-13.8).

CONCLUSION

These results confirm two earlier reports and expand the literature by showing that women who are small at birth and who become overweight as adults are at particularly high risk of the development of preeclampsia.

Non-industrialised countries and affluence

The prevalence of type 2 diabetes is rising rapidly in all non-industrialised populations. By 2025, three-quarters of the world's 300 million adults with diabetes will be in non-industrialised countries, and almost a third in India and China alone. There is strong evidence that this epidemic has been triggered by social and economic development and urbanisation, which are associated with general improvements in nutrition and longevity, but also with obesity, reduced physical exercise and other diabetogenic factors. There is evidence too that fetal growth retardation and growth failure in infancy, both still widespread in non-industrialised populations, increase susceptibility to diabetes. An additional factor may be intergenerational effects of gestational diabetes occurring in mothers who grew poorly in early life and become obese as adults. Prevention of type 2 diabetes will require measures to promote exercise and reduce obesity in adults and children, alongside programmes to achieve healthy fetal and infant growth.

Maternal birth weight and cesarean delivery in four race-ethnic groups

OBJECTIVE

We hypothesized that maternal birth weight was associated with the risk of cesarean delivery for nulliparous women.

STUDY DESIGN

In a population-based cohort study, maternal birth data were linked to a Washington State database, including the birth certificates of 18,905 first-born singleton infants (1987-1995).

RESULTS

Among non-Hispanic white subjects, maternal birth weight of 2500 to 3999 g was associated with a 20.9% risk of cesarean delivery, which was the lowest risk, compared with 24.5% for a maternal birth weight <2500 g (P <.05) and 24.0% for a maternal birth weight > or =4000 g (P <.05). Similar patterns of risk were noted among Hispanic and Native American subjects, although the associations did not reach statistical significance. Risk of cesarean delivery was not associated with maternal birth weight among African American subjects. Among non-Hispanic white subjects, the risk of cesarean delivery was 3.23 times greater with a maternal birth weight <2500 g and an infant birth weight > or =4000 g compared with pregnancies with both maternal and infant birth weights between 2500 and 3999 g (P <. 001). Adjustment for socioeconomic factors did not alter these results.

CONCLUSION

Low and high maternal birth weights exert an intergenerational risk of cesarean delivery in nulliparous non-Hispanic white women.