Late cardiovascular consequences of gestational diabetes mellitus

Breastfeeding Associated with Lower Prevalence of Metabolic Syndrome in Women with Gestational Diabetes in the Very Early Postpartum Period

OBJECTIVE

The aim of this study is to examine the association of breastfeeding with metabolic syndrome (MetS) in women with recent gestational diabetes mellitus (GDM) in the very early postpartum (PP) period.

STUDY DESIGN

We performed a secondary analysis of the Balance After Baby Intervention (BABI) study which enrolled women with recent GDM. Data collected during an early (~8 weeks) PP visit were used in this analysis. At this visit, weight, height, waist circumference (WC), blood pressure (BP), fasting plasma glucose (FPG), and lipids were obtained. MetS was classified per National Cholesterol Education Program Adult Treatment Program III (NCEP-ATP III) criteria. We defined breastfeeding as currently breastfeeding or not currently breastfeeding for the main analysis.

RESULTS

Of 181 women enrolled in BABI, 178 were included in this analysis (3 excluded for missing lipids). Thirty-four percent were Hispanic. Of non-Hispanics, 31.5% were White, 18.5% Asian, and 12.9% Black/African American. The prevalence of MetS was 42.9% in women not breastfeeding versus 17.1% in women breastfeeding (p < 0.001; adjusted odds ratio [aOR] = 0.16 [95% confidence interval (CI): 0.06-0.41]). Breastfeeding women had significantly lower odds of FPG ≥100 mg/dL (aOR = 0.36 [95% CI: 0.14-0.95], p = 0.039), HDL < 50 mg/dL (aOR = 0.19 [95% CI: 0.08-0.46], p < 0.001), and triglycerides (TG) ≥ 150 mg/dL (aOR = 0.26 [95% CI: 0.10-0.66], p = 0.005). When evaluated as continuous variables, WC, FPG, and TG were significantly lower and HDL significantly higher in women breastfeeding in the very early PP period (vs. not breastfeeding).

CONCLUSION

In a diverse population of women with recent GDM, there was lower prevalence of MetS in women breastfeeding compared with those not breastfeeding in the very early PP period. This study extends the findings of an association of breastfeeding with MetS previously reported at time points more remote from pregnancy to the very early PP period and to an ethnically and racially diverse population.

KEY POINTS

· MetS prevalence in women with recent GDM was lower in breastfeeding than not breastfeeding women.. · FPG, HDL, WC, and TG were improved in the breastfeeding group.. · This study extends prior findings to the very early PP period and to a diverse population..

O-GlcNAc transferase contributes to sex-specific placental deregulation in gestational diabetes

INTRODUCTION

Gestational diabetes (GDM) is traditionally thought to emerge from placental endocrine dysregulations, but recent evidence suggests that fetal sex can also impact GDM development. Understanding the molecular mechanisms through which sex modulates placenta physiology can help identify novel molecular targets for future clinical care. Thus, we investigated the nutrient-sensing O-GlcNAc pathway as a potential mediator of sex-specific placenta dysfunction in GDM.

METHODS

Expression levels of O-GlcNAc enzymes were measured in male and female (n = 9+/gender) human placentas based on the maternal diagnosis of GDM. We then simulated the observed differences in both BeWo cells and human syncytiotrophoblasts primary cells (SCT) from male and female origins (n = 6/gender). RNA sequencing and targeted qPCR were performed to characterize the subsequent changes in the placenta transcriptome related to gestational diabetes.

RESULTS

O-GlcNAc transferase (OGT) expression was significantly reduced only in male placenta collected from mothers with GDM compared to healthy controls. Similar downregulation of OGT in trophoblast-like BeWo male cells demonstrated significant gene expression deregulations that overlapped with known GDM-related genes. Notably, placental growth hormone (GH) production was significantly elevated, while compensatory factors against GH-related insulin resistance were diminished. Inflammatory and immunologic factors with toxic effects on pancreatic β cell mass were also increased, altogether leaning toward a decompensatory diabetic profile. Similar changes in hormone expression were confirmed in male human primary SCTs transfected with siOGT. However, down-regulating OGT in female primary SCTs did not impact hormone production.

CONCLUSION

Our study demonstrated the significant deregulation of placental OGT levels in mothers with GDM carrying a male fetus. When simulated in vitro, such deregulation impacted hormonal production in BeWo trophoblast cells and primary SCTs purified from male placentas. Interestingly, female placentas were only modestly impacted by OGT downregulation, suggesting that the sex-specific presentation observed in gestational diabetes could be related to O-GlcNAc-mediated regulation of placental hormone production.

Cardiovascular Disease-Associated MicroRNAs as Novel Biomarkers of First-Trimester Screening for Gestational Diabetes Mellitus in the Absence of Other Pregnancy-Related Complications

We assessed the diagnostic potential of cardiovascular disease-associated microRNAs for the early prediction of gestational diabetes mellitus (GDM) in singleton pregnancies of Caucasian descent in the absence of other pregnancy-related complications. Whole peripheral venous blood samples were collected within 10 to 13 weeks of gestation. This retrospective study involved all pregnancies diagnosed with only GDM (n = 121) and 80 normal term pregnancies selected with regard to equality of sample storage time. Gene expression of 29 microRNAs was assessed using real-time RT-PCR. Upregulation of 11 microRNAs (miR-1-3p, miR-20a-5p, miR-20b-5p, miR-23a-3p, miR-100-5p, miR-125b-5p, miR-126-3p, miR-181a-5p, miR-195-5p, miR-499a-5p, and miR-574-3p) was observed in pregnancies destinated to develop GDM. Combined screening of all 11 dysregulated microRNAs showed the highest accuracy for the early identification of pregnancies destinated to develop GDM. This screening identified 47.93% of GDM pregnancies at a 10.0% false positive rate (FPR). The predictive model for GDM based on aberrant microRNA expression profile was further improved via the implementation of clinical characteristics (maternal age and BMI at early stages of gestation and an infertility treatment by assisted reproductive technology). Following this, 69.17% of GDM pregnancies were identified at a 10.0% FPR. The effective prediction model specifically for severe GDM requiring administration of therapy involved using a combination of these three clinical characteristics and three microRNA biomarkers (miR-20a-5p, miR-20b-5p, and miR-195-5p). This model identified 78.95% of cases at a 10.0% FPR. The effective prediction model for GDM managed by diet only required the involvement of these three clinical characteristics and eight microRNA biomarkers (miR-1-3p, miR-20a-5p, miR-20b-5p, miR-100-5p, miR-125b-5p, miR-195-5p, miR-499a-5p, and miR-574-3p). With this, the model identified 50.50% of GDM pregnancies managed by diet only at a 10.0% FPR. When other clinical variables such as history of miscarriage, the presence of trombophilic gene mutations, positive first-trimester screening for preeclampsia and/or fetal growth restriction by the Fetal Medicine Foundation algorithm, and family history of diabetes mellitus in first-degree relatives were included in the GDM prediction model, the predictive power was further increased at a 10.0% FPR (72.50% GDM in total, 89.47% GDM requiring therapy, and 56.44% GDM managed by diet only). Cardiovascular disease-associated microRNAs represent promising early biomarkers to be implemented into routine first-trimester screening programs with a very good predictive potential for GDM.

Impact of prior gestational diabetes on long-term type 2 diabetes complications

AIMS

While women with gestational diabetes mellitus (GDM) have a higher risk of developing type 2 diabetes mellitus (T2DM) and at a younger age, it is unknown whether T2DM following GDM is associated with worse clinical outcomes. This study aims to examine the impact of GDM on subsequent development of long-term complications of T2DM.

METHODS

All women with T2DM from the National Health and Nutrition Examination Survey (NHANES), a nationally representative cross-sectional survey of US population, between 2007 and 2018 (n = 2494) were stratified into two groups: those with a history of GDM (n = 385) and those without (n = 2109). Rates of macrovascular and microvascular complications of T2DM were compared between the two groups using bivariate and multivariate analyses.

RESULTS

Of 2494 participants with T2DM included in the analysis, 385 (15.4 %) had a history of GDM and 2109 (84.6 %) did not. A history of GDM was independently associated with increased risk of myocardial infarction (aOR 2.53, 95%Cl: 1.18-5.40) and likely coronary artery disease (aOR 2.15, 95 % Cl: 1.00-4.66).

CONCLUSIONS

In this cohort, women with T2DM and a history of GDM had higher risk of macrovascular complications of myocardial infarction and coronary artery disease, compared to those with no history of gestational diabetes.

A 646C > G (rs41423247) polymorphism of the glucocorticoid receptor as a risk factor for hyperglycaemia diagnosed in pregnancy-data from an observational study

AIM

Hyperglycaemia diagnosed in pregnancy (HiP) is a serious and frequent complication of pregnancy, increasing the risk for adverse maternal and neonatal outcomes. Investigate whether allelic variations of the glucocorticoid receptor are related to an increased risk of HiP.

METHOD

The following polymorphisms of the glucocorticoid receptor (GR) were investigated in the cohort study of N = 197 pregnant women with HiP and N = 133 normoglycemic pregnant controls: 646C > G (rs41423247), N363S (rs6195), ER23/22EK (rs6190, rs6189).

RESULTS

A GG variant of the rs41423247 polymorphism was associated with a significantly higher risk for HiP: OR 1.94 (1.18; 3.18), p = 0.009. The relationship remained significant after controlling for maternal age and prepregnancy BMI: OR 3.09 (1.25; 7.64), p = 0.014.

CONCLUSIONS

The allelic GG variant of the 646C > G (rs41423247) polymorphism is associated with an increased risk for hyperglycaemia in pregnancy.

Changing environment of hyperglycemia in pregnancy: Gestational diabetes and diabetes mellitus in pregnancy

The diagnosis and treatment of gestational diabetes mellitus (GDM) have been in a state of flux since the World Health Organization accepted and endorsed the International Diabetes and Pregnancy Study Group's diagnostic pathway and criteria in 2013. These new diagnostic criteria identify an increasing number of women at risk of hyperglycemia in pregnancy (HGiP). Maternal hyperglycemia represents a significant risk to the mother and fetus, in both the short and long term. Controversially, metformin use for the treatment of GDM is increasing in Australia. This article identifies the multiple and varied presentations of HGiP, of which GDM is the most commonly encountered. The degree of maternal hyperglycemia experienced affects the outcomes for both the mother and neonate, and specific diagnosis determines the appropriate treatment for the pregnancy. Given the increasing incidence of women with dysglycemia and those developing HGiP, this is an important area for research and clinical attention for all health professionals.

Risk of gestational diabetes mellitus in relation to plasma concentrations of amino acids and acylcarnitines: A nested case-control study

AIMS

Gestational diabetes mellitus (GDM) affects between 5 and 10% of all pregnancies in Canada and can lead to adverse health outcomes in both the mother and fetus. Amino acids (AA) and acylcarnitines (AC) have been identified as early biomarkers of type 2 diabetes but their usefulness in screening for GDM has yet to be demonstrated.

METHODS

We conducted a nested case-control study involving 50 controls and 50 GDM cases diagnosed between the 24th and 28th week of gestation. Heparinized plasma samples were obtained during the first and early second trimester of pregnancy. Case and controls were matched according to date of recruitment, maternal age, gestational age at blood sampling as well as pre-pregnancy body mass index. Eight AA and eight AC were quantified using an ultra-high pressure liquid-chromatography quadrupole time-of-flight mass spectrometry platform. Conditional regression analyses adjusted for matching factors and smoking habits during pregnancy were performed to identify plasma metabolites associated with GDM risk.

RESULTS

Odds ratio (OR) and 95% confidence interval (CI) for the prediction of GDM per one standard deviation increase of AA or AC in plasma levels were 0.25 (0.08-0.79) for butyrylcarnitine, 0.31 (0.12-0.79) for glutamic acid, 2.5 (1.2-5.3) for acetylcarnitine, 2.9 (1.3-6.8) for isobutyrylcarnitine and 5.3 (1.7-17.0) for leucine. These five metabolites were selected by stepwise conditional logistic regression to create a predictive model with an OR of 2.7 (1.5-4.9).

CONCLUSION

Whether the identified metabolites can predict the risk of developing GDM requires additional studies in a larger sample of pregnant women.

Metabolic disorders during pregnancy and postpartum cardiometabolic risk

Hormonal changes during pregnancy can trigger gestational diabetes (GDM), which is constantly increasing. Its main characteristic is pronounced insulin resistance, but it appears to be a multifactorial process involving several metabolic factors; taken together, the latter leads to silent or clinically evident cardiovascular (CV) events. Insulin resistance and central adiposity are of crucial importance in the development of metabolic syndrome, and they appear to correlate with CV risk factors, including hypertension and atherogenic dyslipidaemia. Hypertensive disease of pregnancy (HDP) is more likely to be an accompanying co-morbidity in pregnancies complicated with GDM. There is still inconsistent evidence as to whether or not co-existent GDM and HDP have a synergistic effects on postpartum risk of cardiometabolic disease; however, this synergism is becoming more accepted since both these conditions may promote endothelial inflammation and early atherosclerosis. Regardless of the presence or absence of the synergism between GDM and HDP, these conditions need to be dealt early enough, in order to reduce CV morbidity and to improve health outcomes for both women and their offspring.

Association of History of Gestational Diabetes With Long-term Cardiovascular Disease Risk in a Large Prospective Cohort of US Women

IMPORTANCE

Previous studies identify gestational diabetes (GD) as a risk factor for intermediate markers of cardiovascular disease (CVD) risk; however, few are prospective, evaluate hard CVD end points, or account for shared risk factors including body weight and lifestyle.

OBJECTIVE

To prospectively evaluate history of GD in relation to incident CVD risk.

DESIGN, SETTING, AND PARTICIPANTS

The Nurses' Health Study II (NHS II) is an observational cohort study of US female nurses established in 1989, with ongoing follow-up. Biennial questionnaires updated behavioral characteristics, health outcomes, and lifestyle factors. Multivariable Cox models estimated the hazard ratio (HR) and 95% CI for CVD risk. We included 89 479 women who reported at least 1 pregnancy and were free of CVD and cancer at baseline. Follow-up through May 31, 2015, was complete for more than 90% of eligible participants.

EXPOSURES

History of GD was self-reported at baseline (1989) via questionnaire and updated every 2 years.

MAIN OUTCOMES AND MEASURES

We observed 1161 incident self-reported nonfatal or fatal myocardial infarction or stroke, confirmed via medical records.

RESULTS

Participants had a mean (SD) age of 34.9 (4.7) years. Adjusting for age, prepregnancy body mass index, and other covariates, GD vs no GD was associated with subsequent CVD (HR, 1.43; 95% CI, 1.12-1.81). Additional adjustment for weight gain since pregnancy and updated lifestyle factors attenuated the association (HR, 1.29; 95% CI, 1.01-1.65). Classifying GD by progression to T2D in relation to CVD risk indicated a positive association for GD with progression to T2D vs no GD or T2D (HR, 4.02; 95% CI, 1.94-8.31), and an attenuated relationship for GD only (HR, 1.30; 95% CI, 0.99-1.71).

CONCLUSIONS AND RELEVANCE

Gestational diabetes was positively associated with CVD later in life, although the absolute rate of CVD in this younger cohort of predominantly white women was low. This relationship is possibly mediated in part by subsequent weight gain and lack of healthy lifestyle.

History of Gestational Diabetes Mellitus in Relation to Cardiovascular Disease and Cardiovascular Risk Factors in US Women

BACKGROUND

Findings from previous studies examining the association between gestational diabetes mellitus (GDM) and subsequent risk of cardiovascular disease (CVD) have been inconsistent and inconclusive. We aimed to examine the associations of a previous history of GDM with risk of CVD and status of cardiovascular risk factors in a nationwide population-based study in the United States.

METHODS

This study included 8,127 parous women aged 20 years or older in the 2007-2014 cycles of the National Health and Nutrition Examination Survey in the United States. The exposure was self-reported diagnostic history of GDM and the outcomes were self-reported diagnostic history of CVD and measurements of cardiovascular risk factors, including blood pressure and blood lipids. Regression models with sample weights were used to examine the associations of GDM with CVD and cardiovascular risk factors.

RESULTS

Among women with a history of both GDM and CVD, CVD was diagnosed on average 22.9 years after the diagnosis of GDM. After adjustment for demographic, socioeconomic, and lifestyle factors, a history of GDM was associated with 63% higher odds of CVD [odds ratio (OR) 1.63, 95% confidence interval (CI) 1.02, 2.62, p-value = 0.04]. Further adjustment for body mass index (BMI) modestly attenuated the association (OR 1.52, 95% CI 0.95, 2.44, p-value = 0.08). A history of GDM was significantly associated with lower serum level of HDL-cholesterol (adjusted β-coefficient -3.33, 95% CI -5.17, -1.50, p-value ≤ 0.001), but not associated with total cholesterol, LDL-cholesterol, triglycerides, or systolic or diastolic blood pressure. Similarly, the association between a history of GDM and HDL cholesterol was attenuated after additional adjustment for BMI (adjusted β-coefficient -1.68, 95% CI -3.38, 0.03, p-value = 0.54).

CONCLUSION

Women with a previous history of GDM have significantly higher risk for developing CVD and lower serum level of HDL cholesterol, compared to women without a history of GDM. The associations may be explained, at least partly, by BMI.

Diagnosis and risk stratification of women with stable ischemic heart disease

Although mortality rates for cardiovascular disease are on the decline, it remains the leading cause of death among men and women in the United States. Until recently, more women died of heart disease every year than men. Significant effort has been focused on increasing the awareness of cardiovascular disease among women, but ethnic disparities in awareness still exist. Early symptom recognition, risk assessment, and diagnosis of CAD are paramount in reducing cardiovascular morbidity and mortality in women. This review will highlight the unique risk factors for CAD in women, variability in clinical presentation for ischemic heart disease, and risk stratification for CAD in symptomatic women.

A preliminary study on human placental tissue impaired by gestational diabetes: a comparison of gel-based versus gel-free proteomics approaches

Gestational diabetes (GDM) is the most common complication of pregnancy and it is associated with maternal and fetal short- and long-term consequences. GDM modifies placental structure and function, but many of the underlying mechanisms are still unclear. The aim of this study is to develop and compare two different methods, based respectively on gel-based and gel-free proteomics, in order to investigate the placental proteome in the absence or in the presence of GDM and to identify, through a comparative approach, possible changes in protein expression due to the GDM condition. Placenta homogenates obtained by pooling six control samples and six samples from GDM pregnant women were analyzed by two-dimensional (2D) electrophoresis coupled with mass spectrometry [nano-liquid chromatography (nano-LC) tandem mass spectrometry (MS/MS) and matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS)] and by a label-free mass spectrometry method based on LC-MS(E). The gel-based approach highlights 13 over-expressed proteins and 16 under-expressed proteins, while the label-free method shows the over- expression of 10 proteins and the under-expression of nine proteins. As regards 2D gel electrophoresis, a comparison between two different protein identification methods, based respectively on nLC-electrospray ionization-MS/MS and MALDI-MS/MS, was performed taking into consideration the sequence coverage, the MASCOT score and the exponentially modified protein abundance index. The analysis of the complex proteome through an integrated strategy revealed that the quantitative gel-free and label-free MS approach might be suitable to identify candidate markers of GDM.

Changes in lipid profile after treatment of women with gestational diabetes mellitus

BACKGROUND

Insulin resistance, a key factor in the pathophysiology of gestational diabetes mellitus (GDM), is associated with an atherogenic lipid profile. Lipid metabolism is altered during normal pregnancy, but it is still unknown how the treatment of GDM affects lipoprotein concentrations.

OBJECTIVE

To evaluate maternal lipids at GDM diagnosis, after treatment, and in the puerperium and analyze the influence of BMI, insulin requirement, and glycemic control on lipoproteins.

METHODS

In this observational prospective study, total cholesterol (TC), HDL, and triglycerides (TG) were measured, and LDL was calculated at diagnosis (Dx), at 3-6 weeks after GDM treatment initiation (PI, post initiation) and 6-week postpartum (PP). Subgroups analyses were performed according to categories of maternal BMI, insulin requirement, and quality of glucose control.

RESULTS

TC and TG increased from Dx to PI and decreased in PP (TC: 213.6 mg/dL, 223.9 mg/dL, and 195.5 mg/dL; TG: 181.5 mg/dL, 203.5 mg/dL, and 100.5 mg/dL, at Dx, PI, and PP, respectively; P < .0001). HDL declined in the puerperium (Dx = 60 mg/dL, PI = 60.8 mg/dL, PP = 51.8 mg/dL; P < .0001 for Dx-PP and PI-PP, respectively). Insulin-treated patients showed an increase in LDL from Dx to PP, whereas LDL declined in the diet-only group (12 vs -11.1 mg/dL, P = .010). TC and TG increased from Dx to PI in patients with adequate glycemic control and decreased in the uncontrolled subgroup (TC: 15.5 vs -1.2 mg/dL, P = .041; TG: 29.7 vs -12.5 mg/dL, P = .07). No significant differences in lipids variation were observed according to BMI.

CONCLUSIONS

Insulin requirement and glycemic control status directly affected the variation of lipid profile in women with GDM.

Hypertension Risk Subsequent to Gestational Dysglycemia Is Modified by Race/Ethnicity

Gestational diabetes mellitus is associated with an increased risk of type 2 diabetes mellitus and hypertension. Additionally, gestational dysglycemia has been associated with an increased risk of type 2 diabetes mellitus but not yet associated with hypertension subsequent to pregnancy in long-term follow-up. Therefore, we set out to examine this relationship as well as the role of race/ethnicity in modifying this relationship. We analyzed a prospective observational cohort followed between 1998 and 2007. There were 17 655 women with self-reported race/ethnicity and full-term, live births. A 1-hour 50 g oral glucose-load test and a 3-hour 100 g oral glucose-tolerance test enabled third trimester stratification of women into 1 of 4 glucose-tolerance groups: (1) normal (n=15 056); (2) abnormal glucose-load test (n=1558); (3) abnormal glucose-load and -tolerance tests (n=520); and (4) gestational diabetes mellitus (n=521). Women were then followed for a mean±standard deviation of 4.1±2.9 years after delivery for the development of hypertension. Although gestational diabetes mellitus was associated with an increased risk of hypertension after pregnancy (odds ratio [95% confidence interval]: 1.58 [1.02, 2.45]; P=0.04), dysglycemia defined by an abnormal glucose-load test predicted hypertension only among black women (4.52 [1.24, 16.52]; P=0.02). The risk of hypertension after pregnancy among dysglycemia groups not meeting criteria for gestational diabetes mellitus varied based on the race/ethnicity of the population. Further research on the implications of the intersection of race/ethnicity and gestational dysglycemia on subsequent hypertension is warranted.

A systematic review of metabolite profiling in gestational diabetes mellitus

AIMS/HYPOTHESIS

Gestational diabetes mellitus is associated with adverse maternal and fetal outcomes during, as well as subsequent to, pregnancy, including increased risk of type 2 diabetes and cardiovascular disease. Because of the importance of early risk stratification in preventing these complications, improved first-trimester biomarker determination for diagnosing gestational diabetes would enhance our ability to optimise both maternal and fetal health. Metabolomic profiling, the systematic study of small molecule products of biochemical pathways, has shown promise in the identification of key metabolites associated with the pathogenesis of several metabolic diseases, including gestational diabetes. This article provides a systematic review of the current state of research on biomarkers and gestational diabetes and discusses the clinical relevance of metabolomics in the prediction, diagnosis and management of gestational diabetes.

METHODS

We conducted a systematic search of MEDLINE (PubMed) up to the end of February 2014 using the key term combinations of 'metabolomics,' 'metabonomics,' 'nuclear magnetic spectroscopy,' 'mass spectrometry,' 'metabolic profiling' and 'amino acid profile' combined (AND) with 'gestational diabetes'. Additional articles were identified through searching the reference lists from included studies. Quality assessment of included articles was conducted through the use of QUADOMICS.

RESULTS

This systematic review included 17 articles. The biomarkers most consistently associated with gestational diabetes were asymmetric dimethylarginine and NEFAs. After QUADOMICS analysis, 13 of the 17 included studies were classified as 'high quality'.

CONCLUSIONS/INTERPRETATION

Existing metabolomic studies of gestational diabetes present inconsistent findings regarding metabolite profile characteristics. Further studies are needed in larger, more racially/ethnically diverse populations.

Dietary self-efficacy predicts AHEI diet quality in women with previous gestational diabetes

PURPOSE

The purpose of this study was to examine the association of intrapersonal influences of diet quality as defined by the Health Belief Model constructs in women with recent histories of gestational diabetes.

METHODS

A descriptive, correlational, cross-sectional design was used to analyze relationships between diet quality and intrapersonal variables, including perceptions of threat of type 2 diabetes mellitus development, benefits and barriers of healthy eating, and dietary self-efficacy, in a convenience sample of 75 community-dwelling women (55% minority; mean age, 35.5 years; SD, 5.5 years) with previous gestational diabetes mellitus. Diet quality was defined by the Alternative Healthy Eating Index (AHEI). Multiple regression was used to identify predictors of AHEI diet quality.

RESULTS

Women had moderate AHEI diet quality (mean score, 47.6; SD, 14.3). Only higher levels of education and self-efficacy significantly predicted better AHEI diet quality, controlling for other contributing variables.

CONCLUSIONS

There is a significant opportunity to improve diet quality in women with previous gestational diabetes mellitus. Improving self-efficacy may be an important component to include in nutrition interventions. In addition to identifying other important individual components, future studies of diet quality in women with previous gestational diabetes mellitus are needed to investigate the scope of influence beyond the individual to potential family, social, and environmental factors.

The importance of gestational diabetes beyond pregnancy

Diabetes mellitus is the main health problem affecting Mexico's population. The mechanisms by which susceptibility to it is acquired and diabetes develops are topics of ongoing research. In order to prevent type 2 diabetes, one of the challenges is to fully understand gestational diabetes and the hormonal changes and altered carbohydrate metabolism that are associated with it during fetal development. A recent study by the Instituto Nacional de Perinatología found a 12.9% prevalence of gestational diabetes; if the current criteria suggested by the American Diabetes Association were applied, this figure would rise to almost 30%. Identifying mothers and children at high risk of developing diabetes mellitus and its comorbid conditions will help facilitate the timely implementation of preventive measures. This will be a rational use of economic resources in Mexico that will vitally benefit public health.

Placental histomorphometry in gestational diabetes mellitus: the relationship between subsequent type 2 diabetes mellitus and race/ethnicity

OBJECTIVES

We examined placental histomorphometry in gestational diabetes mellitus (GDM) for factors associated with race/ethnicity and subsequent type 2 diabetes mellitus (T2DM).

METHODS

We identified 124 placentas from singleton, full-term live births whose mothers had clinically defined GDM and self-reported race/ethnicity. Clinical and placental diagnoses were abstracted from medical records.

RESULTS

Forty-eight white and 76 nonwhite women were followed for 4.1 years (median, range 0.0-8.9 years). White women developed less T2DM (12.5% vs 35.5%; P = .005) but had higher systolic (mean ± SD, 116 ± 13 vs 109 ± 11 mm Hg; P < .001) and diastolic (71 ± 9 vs 68 ± 7 mm Hg; P = .02) blood pressure, more smoking (35.4% vs 10.5%; P = .004), and more chorangiosis (52.1% vs 30.3%; P = .02) than nonwhite women.

CONCLUSIONS

Although more nonwhite women developed T2DM, more white women had chorangiosis, possibly secondary to the higher percentage of smokers among them. Further study is necessary to elucidate the relationship among chorangiosis, subsequent maternal T2DM, and race.

Dulce Mothers: an intervention to reduce diabetes and cardiovascular risk in Latinas after gestational diabetes

Latina women with prior gestational diabetes mellitus (GDM) are at elevated risk for type 2 diabetes mellitus and cardiovascular disease. Few primary prevention programs are designed for low socioeconomic status, Spanish-speaking populations. We examined the effectiveness of a Diabetes Prevention Program (DPP) translation in low-income Latinas with a history of GDM. Eighty-four Latinas, 18-45 years old with GDM in the past 3 years, underwent an 8-week peer-educator-led group intervention, with tailoring for Latino culture and recent motherhood. Lifestyle changes and diabetes and cardiovascular risk factors were assessed at study baseline, month 3 and month 6. Participants showed significant improvements in lipids, blood pressure, physical activity, dietary fat intake, and fatalistic and cultural diabetes beliefs (p < 0.05). Formative evaluation provides preliminary evidence of program acceptability. A peer-led, culturally appropriate DPP translation was effective in improving lifestyle changes and some indicators of cardiovascular and diabetes risk in Latinas with GDM.

History of gestational diabetes mellitus and future risk of atherosclerosis in mid-life: the Coronary Artery Risk Development in Young Adults study

BACKGROUND

History of gestational diabetes mellitus (GDM) increases lifetime risk of type 2 diabetes (DM) and the metabolic syndrome (MetS), which increase risk of cardiovascular disease. It is unclear, however, whether GDM increases risk of early atherosclerosis independent of pre-pregnancy obesity and subsequent metabolic disease.

METHODS AND RESULTS

Of 2787 women (18 to 30 years) enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) study, we studied 898 (47% black) who were free of DM and heart disease at baseline (1985-1986), delivered ≥1 post-baseline births, reported GDM history, and had common carotid intima media thickness (ccIMT, mm) measured in 2005-2006. We used multivariable linear regression to assess associations between GDM and ccIMT adjusted for race, age, parity, and pre-pregnancy cardiometabolic risk factors. We assessed mediators (weight gain, insulin resistance, blood pressure), and effect modification by incident DM or MetS during the 20-year period. Of the 898 women, 119 (13%) reported GDM (7.6 per 100 deliveries). Average age was 31 at last birth and 44 at ccIMT measurement for GDM and non-GDM groups. Unadjusted mean ccIMT was 0.023 mm higher for GDM than non-GDM groups (P=0.029), but pre-pregnancy BMI attenuated the difference to 0.016 mm (P=0.109). In 777 women without subsequent DM or the MetS, mean ccIMT was 0.023 mm higher for GDM versus non-GDM groups controlling for race, age, parity, and pre-pregnancy BMI (0.784 versus 0.761, P=0.039). Addition of pre-pregnancy insulin resistance index had minimal impact on adjusted mean net ccIMT difference (0.22 mm). Mean ccIMT did not differ by GDM status among 121 women who developed DM or the MetS (P=0.58).

CONCLUSIONS

History of GDM may be a marker for early atherosclerosis independent of pre-pregnancy obesity among women who have not developed type 2 diabetes or the metabolic syndrome.

Recognizing pregnancy-associated cardiovascular risk factors

Preeclampsia, gestational diabetes, or pregnancy-induced hypertension identify a woman at risk for cardiovascular disease. This information should be incorporated into the routine cardiovascular risk assessment for women, as a basis for appropriate risk factor screening, counseling, and preventive interventions. There is need for development and validation of a clinometric tool to assess cardiovascular risk and guide management.

Gestational diabetes and risk of cardiovascular disease: a scoping review

BACKGROUND

Gestational diabetes mellitus is associated with an increased risk of incident type 2 diabetes and has deleterious effects on other cardiovascular risk factors. However, the effect of gestational diabetes on the risk of cardiovascular disease remains unclear. We conducted a scoping review of the literature to examine the association between these 2 conditions.

METHODS

We systematically searched the PubMed and Embase databases for studies examining the association between gestational diabetes and cardiovascular disease. We restricted our search to studies involving humans that were published in English or French. Outcomes of interest included acute coronary syndromes, angina, arrhythmia, coronary artery disease, heart failure, myocardial infarction, stroke, and composite end points with these outcomes.

RESULTS

A total of 11 publications (3 cohort studies [1 published as an abstract], 2 cross-sectional studies, 1 case-control study [published as an abstract], 4 narrative reviews, and 1 editorial) met our inclusion criteria. The 2 cohort studies published as full manuscripts were conducted in overlapping populations. The included studies reported a range of adjusted relative risks for incident cardiovascular disease, from not significant to 1.85 (95% confidence interval [CI] 1.21 to 2.82). Adjustment for subsequent type 2 diabetes mellitus attenuated the effects but with wide 95% CIs that spanned unity (range 1.13 [95% CI 0.67 to 1.89] to 1.56 [95% CI 1.00 to 2.43]).

INTERPRETATION

Available data suggest that gestational diabetes is associated with an increased risk of cardiovascular disease. However, these data are limited, and evidence regarding this association independent of the increased risk due to subsequent type 2 diabetes and other risk factors for cardiovascular disease remains inconclusive.

Cardiometabolic risk, knowledge, risk perception, and self-efficacy among American Indian women with previous gestational diabetes

OBJECTIVE

To describe cardiometabolic risk among a sample of American Indian women with previous gestational diabetes and describe the women's knowledge, risk perception for type 2 diabetes and cardiovascular disease, and self-efficacy beliefs related to preventing these diseases.

DESIGN

Mixed methods, cross-sectional, exploratory, descriptive.

SETTING

Four campuses within one American Indian tribal health care system in a southwestern state.

PARTICIPANTS

A purposeful sample of 22 self-identified American Indian women with a history of gestational diabetes.

METHODS

Qualitative interview data were subjected to content analysis, and descriptive statistics were used to analyze quantitative questionnaire data and biophysiologic data.

RESULTS

The majority of participants (13 of 21) were classified as having metabolic syndrome, and 13 of 18 women were found to be insulin resistant. In general, the women had high levels of knowledge related to type 2 diabetes and cardiovascular disease and high risk perception, but low self-efficacy related to preventing cardiometabolic disease. The overarching theme from the in-depth interviews, struggling to change lifestyle behaviors while doubting prevention is possible, encompassed four categories that provided further illumination into participants' risk perceptions and self-efficacy beliefs: concerns, control, beliefs/attitudes, and prevention.

CONCLUSIONS

High levels of knowledge and risk perception do not necessarily promote increased self-efficacy to prevent cardiometabolic disease among American Indian women with previous gestational diabetes. Findings indicate the need to further explore women's self-efficacy beliefs in the context of American Indian culture prior to developing interventions aimed at increasing self-efficacy to prevent or delay type 2 diabetes and cardiovascular disease. Women with previous gestational diabetes are at increased risk for developing cardiovascular disease, independent of a diagnosis of type 2 diabetes.

Association of female reproductive factors with body composition: the Framingham Heart Study

BACKGROUND

Identifying reproductive risk factors in women offers a life course approach to obesity and cardiovascular disease prevention. The association of female reproductive factors with measures of regional body fat distribution has not been comprehensively studied.

METHODS

We examined the association of female reproductive factors (age at menarche, parity, age at natural menopause, menopausal status) in association with body composition data from women who participated in the Offspring and the Third Generation Framingham Heart Study cohorts. Visceral adipose tissue (VAT) and sc adipose tissue (SAT) were measured volumetrically by multidetector computerized tomography. We modeled the relationship between each fat depot and female reproductive factors after adjusting for various factors such as age, smoking status, alcohol intake, physical activity index, hormone replacement therapy, and menopausal status.

RESULTS

Earlier age at menarche was associated with increased body mass index (BMI), waist circumference (WC), VAT, and SAT (P < 0.0001). This association of earlier menarche with adiposity measures was attenuated after adjusting for BMI (all P > 0.70). We observed no association between parity and all parameters of adiposity measurements (all P > 0.24). Similarly, age at natural menopause was not associated with measures of body composition. Despite higher mean BMI among the post- (BMI 27.3 kg/m(2)) compared with the premenopausal women (BMI 25.9 kg/m(2)) in an age-matched analysis, mean VAT was not different between the two groups (P = 0.30).

CONCLUSIONS

Earlier menarche is associated with overall obesity but not with VAT or SAT after accounting for measures of generalized adiposity. Parity and menopausal age were not associated with adiposity measures. Although postmenopausal women had increased BMI, VAT, and SAT, the association was predominantly due to age.

Follow-up of women with gestational diabetes in the Tehran Lipid and Glucose Study (TLGS): a population-based cohort study

AIM

Women with gestational diabetes (GDM) are at increased risk of developing type 2 diabetes mellitus (T2DM), but there is disagreement regarding this conversion rate or its cardiovascular consequences. We investigated the metabolic and cardiovascular consequences of women with GDM in a population-based cohort study.

MATERIAL AND METHODS

Three groups of women were selected from the Tehran Lipid and Glucose Study (TLGS) and followed up for an average 9 years: women with prior history of GDM (n = 29); women with history of macrosomia or stillbirth without GDM (MC-ST) (n = 570), and age- and BMI-matched controls (n = 628). The incidence of T2DM, hypertension (HTN) and dyslipidemia were compared between these groups. Statistical significance was set at P < 0.05.

RESULTS

During the 9-year follow-up, T2DM was diagnosed in 27.3% of women with GDM in comparison to 9.5% among the control group (P < 0/001); 7.4% of the MC-ST group versus 8.9% of control group developed T2DM during the study follow-up (P = 0/03). There was no significant difference in the incidence of HTN or dyslipidemia between these groups (P > 0/05).

CONCLUSION

Women with a history of GDM are at higher risk for developing T2DM later in life. The timely recognition of GDM may provide a 'teachable moment' during which women could be motivated to implement lifestyle modifications to reduce their T2DM risk.

Insulin need in gestational diabetes is associated with a worse cardiovascular risk profile after pregnancy

OBJECTIVE

Women with gestational diabetes mellitus (GDM) treated with insulin are more likely to develop type 2 diabetes after pregnancy compared to mild GDM cases treated with medical nutrition treatment (MNT) alone. We aimed to compare levels of subclinical atherosclerosis markers in women with previous GDM treated with insulin and MNT alone.

METHODS

Eighty-one women with previous GDM (45 treated with insulin, 36 treated with MNT) and 35 age-matched lean controls were included. Fasting glucose, insulin and lipids, circulating fibrinogen, CRP, PAI-1 and IL-6 levels were assayed. Carotid intima media thickness (IMT) was measured.

RESULTS

Women with previous GDM treated with insulin in pregnancy had significantly higher fasting glucose, plasma PAI-1 levels and carotid IMT compared to women treated with MNT alone. In multiple regression analysis, insulin need in pregnancy was associated with increased carotid IMT and plasma PAI-1 levels (corrected for age, BMI, postpartum duration, fasting glucose and lipids; model r(2)=0.132; beta=0.297, p=0.014 for carotid IMT; model r(2)=0.198; beta=0.345, p=0.003 for PAI-1).

CONCLUSION

Women with previous GDM treated with insulin in pregnancy had a worse cardiovascular risk profile compared to mild GDM patients. An intensive preventive approach for cardiovascular disorders is particularly essential for this subgroup of women.

Previous gestational diabetes mellitus and markers of cardiovascular risk

The prevalence of gestational diabetes mellitus (GDM) in the developed world has increased at an alarming rate over the last few decades. GDM has been shown to be associated with postpartum diabetes, insulin resistance, hypertension, and dyslipidemia. A history of previous GDM (pGDM), associated or not with any of these metabolic abnormalities, can increase the risk of developing not only type 2 diabetes mellitus but also cardiovascular disease (CVD) independent of a diagnosis of type 2 diabetes later in life. In this paper we discuss the relationship among inflammatory markers, metabolic abnormalities, and vascular dysfunction in women with pGDM. We also review the current knowledge on metabolic modifications occurring in normal pregnancy and the link between alterations of a normal metabolic state with the long-term maternal complications that may result in increased CVD risk. Our review of studies on pGDM prompts us to recommend that these women be considered a population at risk for later CVD events, which however could be avoided via the use of specially designed follow-up programs in the future.

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.

Plasma thrombin-activatable fibrinolysis inhibitor levels are not associated with glucose intolerance and subclinical atherosclerosis in women with previous gestational diabetes

We aimed to determine plasma thrombin-activatable fibrinolysis inhibitor (TAFI) antigen levels in women with previous gestational diabetes mellitus (GDM) and to evaluate the possible association of plasma TAFI with glucose intolerance and markers of subclinical atherosclerosis. This cross-sectional study was performed in 111 women with previous GDM and 60 controls. Glucose intolerance was evaluated. Homeostasis model assessment score was calculated. Circulating lipids, interleukin-6, matrix metalloproteinase-1, fibrinogen, plasminogen activator inhibitor-1, and TAFI antigen levels were assayed. Carotid intima media thickness (IMT) was measured. Women with previous GDM had increased levels of atherosclerosis markers and carotid IMT. On the other hand, plasma TAFI antigen levels were similar (P = .395). Thrombin-activatable fibrinolysis inhibitor was not associated with the indices of insulin resistance, glucose intolerance, markers of atherosclerosis, and carotid IMT. Our data demonstrated that plasma TAFI was not altered in women with previous GDM. TAFI was not associated with glucose intolerance and subclinical atherosclerosis.

The association of adverse pregnancy events and cardiovascular disease in women 50 years of age and older

OBJECTIVE

This study investigates the association between a prior history of pregnancy complications and cardiovascular disease (CVD) among Kentucky women aged ≥50 years.

METHODS

Data were analyzed from participants (n = 3909) in the Kentucky Women's Health Registry (2006-2008). Primary outcomes were self-reported prevalence of CVD, including angina, heart attack, heart failure, and arrhythmia. Pregnancy complications used as predictors were preterm labor, preeclampsia, gestational diabetes mellitus (GDM), and third trimester bleeding. Logistic regression analyses were conducted to determine associations between prevalence of CVD and pregnancy complications, controlling for age, education, and smoking status.

RESULTS

Overall, 199 (5.1%) women reported angina, 79 (2.0%) reported heart attack, 44 (1.1%) reported heart failure, and 642 (16.4%) reported arrhythmia. One pregnancy complication was reported by 614 (15.7%) women, and two or more complications were reported by 130 (3.3%) women. In regression models adjusting for age, education, and smoking, compared to women who were never pregnant, women with no pregnancy complications had a similar risk of reporting heart attack (odds ratio [OR] 1.2, 95% confidence interval [CI] 0.5-2.7), but women with one pregnancy complication (OR 2.5, 95% CI 1.03-6.0) and two or more complications (OR 4.2, 95% CI 1.4-10.6) had an increased risk. Similar results were seen for angina and arrhythmia, but not heart failure.

CONCLUSIONS

Women who experience pregnancy complications are more likely to report prevalent CVD (including angina, heart attack, and arrhythmia), suggesting a link between adverse pregnancy events and CVD. Pregnancy complications may serve as signals for future CVD, presenting an opportunity for early intervention and prevention.

Increased osteoprotegerin levels in women with previous gestational diabetes developing metabolic syndrome

Osteoprotegerin (OPG), a novel soluble member of tumour necrosis factor receptor superfamily, has been shown to link cardiovascular disorders. The aim of this study is to investigate the potential relationship between serum OPG levels, cardiovascular risk factors and metabolic syndrome in a relatively large group of women with previous GDM. In this cross-sectional case-control study, 128 women with previous GDM and 67 age-matched controls were enrolled. Subjects were evaluated for the diagnosis of metabolic syndrome according to the criteria of the American Heart Association (AHA). Fasting glucose, insulin, serum lipids, CRP and OPG were assayed. HOMA score was calculated. Carotid intima media thickness (IMT) was measured. There was no significant increase in OPG levels in women with previous GDM when compared to controls. On the other hand, women with previous GDM developing metabolic syndrome had higher OPG levels than those without metabolic syndrome and healthy controls. Serum OPG levels were associated with obesity, insulin resistance, serum CRP and carotid IMT. Serum OPG is related to cardiovascular risk factors and metabolic syndrome, and might be involved in the development of cardiovascular disorders in women with previous GDM.

[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.

Glucose intolerance in pregnancy and postpartum risk of metabolic syndrome in young women

CONTEXT/OBJECTIVE

Gestational diabetes mellitus (GDM) and even mild glucose intolerance in pregnancy are both associated with increased risks of developing type 2 diabetes and cardiovascular disease in the future. Because the metabolic syndrome also identifies patients at risk of type 2 diabetes and cardiovascular disease, we hypothesized that gestational dysglycemia may be associated with an unrecognized latent metabolic syndrome. Thus, we sought to evaluate the relationship between gestational glucose tolerance status and postpartum risk of metabolic syndrome.

DESIGN/SETTING/PARTICIPANTS

In this prospective cohort study, 487 women underwent oral glucose tolerance testing in pregnancy and cardiometabolic characterization at 3 months postpartum. The antepartum testing defined three gestational glucose tolerance groups: GDM (n = 137); gestational impaired glucose tolerance (GIGT) (n = 91); and normal glucose tolerance (NGT) (n = 259).

MAIN OUTCOME MEASURE

The primary outcome was the presence of the metabolic syndrome at 3 months postpartum, as defined by International Diabetes Federation (IDF) and American Heart Association/National Heart Lung and Blood Institute (AHA/NHLBI) criteria, respectively.

RESULTS

The postpartum prevalence of IDF metabolic syndrome progressively increased from NGT (10.0%) to GIGT (17.6%) to GDM (20.0%) (overall P = 0.016). The same progression was observed for AHA/NHLBI metabolic syndrome (NGT, 8.9%; GIGT, 15.4%; and GDM, 16.8%; overall P = 0.046). On logistic regression analysis, both GDM (odds ratio, 2.05; 95% confidence interval, 1.07-3.94) and GIGT (odds ratio, 2.16; 95% confidence interval, 1.05-4.42) independently predicted postpartum metabolic syndrome.

CONCLUSIONS

Both GDM and mild glucose intolerance in pregnancy predict an increased likelihood of metabolic syndrome at 3 months postpartum, supporting the concept that women with gestational dysglycemia may have an underlying latent metabolic syndrome.