Role of diet and insulin treatment of diabetes in pregnancy

Lower daily carbohydrate consumption than recommended by the Institute of Medicine is common among women with type 2 diabetes in early pregnancy in Denmark

AIMS

To secure adequate carbohydrate supply in pregnancy, the Institute of Medicine (IOM) recommends a minimum amount of carbohydrates of 175 g daily. Currently a low carbohydrate diet is a popular health trend in the general population and this might also be common among overweight and obese pregnant women with type 2 diabetes (T2D). Thus, we explored carbohydrate consumption among pregnant women with T2D including women with type 1 diabetes (T1D) for comparison.

METHODS

A retrospective cohort study of consecutive women with T2D (N = 96) and T1D (N = 108), where dietary records were collected at the first antenatal visit.

RESULTS

Among women with T2D and T1D, bodyweight at the first visit was 90.8 ± 22 (mean ± SD) and 75.5 ± 15 kg (P < 0.001) while HbA1c was 6.6 ± 1.2% (49 ± 13 mmol/mol) and 6.6 ± 0.8% (48 ± 8 mmol/mol), P = 0.8, respectively. The average daily carbohydrate consumption from the major carbohydrate sources was similar in the two groups (159 ± 56 and 167 ± 48 g, P = 0.3), as was the level of total daily physical activity (median (interquartile range)): 215 (174-289) and 210 (178-267) metabolic equivalent of task-hour/week (P = 0.9). A high proportion of women with T2D and T1D (52% and 40%, P = 0.08) consumed fewer carbohydrates than recommended by the IOM. The prevalence of ketonuria (≥4 mmol/L) was 1% in both groups.

CONCLUSIONS

In early pregnancy, a lower daily carbohydrate consumption than recommended by the IOM was common among women with T2D. The results were quite similar to women with T1D, despite a markedly higher bodyweight in women with T2D. Reassuringly, ketonuria was rare in both groups.

Metabolic follow-up at one year and beyond of women with gestational diabetes treated with insulin and/or oral hypoglycaemic agents: study protocol for the identification of a core outcomes set using a Delphi survey

BACKGROUND

Gestational diabetes (GDM) is associated with an increased lifetime risk for the development of glucose abnormalities, metabolic syndrome, cardiovascular disease, depression and tumours. Despite this high risk of additional comorbidities, there is no standardised approach to the long-term follow-up of women with a previous diagnosis of GDM. Also, there is no standardisation of outcome selection and reporting in studies involving this population. This increases the risk of reporting bias and reduces the possibility of meaningful comparisons between studies. The aim of this study is to develop a protocol for a core outcome set (COS) for the metabolic follow-up at 1 year and beyond of women with previous GDM treated with insulin and/or oral hypoglycaemic agents.

METHODS/DESIGN

This protocol will describe the steps that will be taken in order to develop the COS. The study will consist of three parts: (1) A systematic review of the literature of the outcomes reported in previous randomised controlled trials of the follow-up at 1 year and beyond of women with GDM treated with insulin and/or oral hypoglycaemic agents; (2) A three-round, online Delphi survey with key stakeholders in order to prioritise these outcomes; and (3) A consensus meeting where the final COS will be decided.

DISCUSSION

The proposed protocol is the first step in developing a COS that will bring consistency and uniformity to outcome selection and reporting in GDM women treated with insulin and/or oral hypoglycaemic agents.

Gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is the most common medical complication of pregnancy. It is associated with maternal and neonatal adverse outcomes. Maintaining adequate blood glucose levels in GDM reduces morbidity for both mother and baby. There is a lack of uniform strategies for screening and diagnosing GDM globally. This review covers the latest update in the diagnosis and management of GDM. The initial treatment of GDM consists of diet and exercise. If these measures fail to achieve glycemic goals, insulin should be initiated. Insulin analogs are more physiological than human insulin, and are associated with less risk of hypoglycemia, and may provide better glycemic control. Insulin lispro, aspart, and detemir are approved to be used in pregnancy. Insulin glargine is not approved in pregnancy, but the existing studies did not show any contraindications. The use of oral hypoglycemic agents; glyburide and metformin seems to be safe and effective in pregnancy.

Enhanced 911/global position system wizard: a telemedicine application for the prevention of severe hypoglycemia--monitor, alert, and locate

Intensive insulin therapy has an inherent risk of hypoglycemia that can lead to loss of consciousness, cardiac arrhythmia, seizure, and death ("dead-in-bed syndrome"). This risk of hypoglycemia is a major concern for patients, families, and physicians. The need for an automated system that can alert in the event of severe hypoglycemia is evident. In engineering systems, where there is a risk of malfunction of the primary control system, alert and safety mechanisms are implemented in layers of protection. This concept has been adopted in the proposed system that integrates a hypoglycemia prediction algorithm with a global position system (GPS) locator and short message service such that the current glucose value with the rate of change (ROC) and the location of the subject can be communicated to a predefined list. Furthermore, if the system is linked to the insulin pump, it can suspend the pump or decrease the basal insulin infusion rate to prevent the pending event. The system was evaluated on clinical datasets of glucose tracings from the DexCom Seven system. Glucose tracings were analyzed for hypoglycemia events and then a text message was broadcast to a predefined list of people who were notified with the glucose value, ROC, GPS coordinates, and a Google map of the location. In addition to providing a safety layer to a future artificial pancreas, this system also can be easily implemented in current continuous glucose monitors to help provide information and alerts to people with diabetes.

A Medical Nutrition Therapy Program Improves Perinatal Outcomes in Mexican Pregnant Women With Gestational Diabetes and Type 2 Diabetes Mellitus

Diabetes in pregnancy is a major public health problem in Mexico. Nutrition therapy is an important component of treatment. Intensive nutrition intervention has not been implemented for Mexican pregnant women with diabetes. Its effect on different types of diabetes mellitus has not been studied.

Purpose

The authors assessed the effect of a medical nutrition therapy (MNT) program on perinatal complications in Mexico City.

Methods

Quasi-experimental design with a historical control. Women were assigned to a MNT program (n = 88) and were followed up with every 2 weeks until delivery (2004-2007). The control group (n = 86) was selected from medical charts (2001-2003) and the same inclusion criteria were used. In each group, 55% of women had type 2 diabetes mellitus and 45% had gestational diabetes. The MNT program included a moderate intake of carbohydrate (40%-45% of total energy) and reduction in energy intake, capillary glucose self-monitoring, and education. The control group received usual hospital routine care. Statistical analysis included descriptive statistics, chi-square, and multivariate logistic regression (OR, 95% CI) as indicated.

Results

Women in the MNT program had a lower risk of preeclampsia, fewer maternal hospitalization, and neonatal deaths in both types of diabetes. Low birth weight was less frequent only in women with gestational diabetes receiving MNT, while neonatal intensive care unit admissions were lower only in women with type 2 diabetes.

Conclusions

An intensive MNT program, including counseling, education, and capillary glucose self-monitoring, has a positive effect over preeclampsia, maternal hospitalization, and neonatal death in women with diabetes in pregnancy. MNT guidelines should be implemented in Mexican health care facilities treating diabetes in pregnancy.

Sonographic evaluation of fetal growth and body composition in women with different degrees of normal glucose metabolism

OBJECTIVE

To investigate the maternal demographic and metabolic factors contributing to the growth of fetal lean and fat body mass in women whose degree of glucose intolerance is less than that defining gestational diabetes in comparison with women with normal glucose metabolism.

RESEARCH DESIGN AND METHODS

Longitudinal sonographic examinations of 66 singleton fetuses without anomalies of nonobese mothers with abnormal oral glucose challenge test (GCT) results and without gestational diabetes (group 1) were compared with those of 123 singleton fetuses without anomalies of nonobese mothers with normal GCT values (group 2). Lean body mass measurements included head circumference, femur length, mid-upper arm, and mid-thigh central areas. Fat body mass measurements included the anterior abdominal wall thickness, the subscapular thickness, and the mid-upper arm and mid-thigh subcutaneous areas. All the women performed a 24-h glucose profile on the day preceding the ultrasound scan. Multivariate logistic regression analysis established best-fit equations for fetal sonographic measurements of fat and lean body mass. Independent variables included groups 1 and 2, maternal age, parity, prepregnancy BMI, gestational age, weight gain during pregnancy, fetal sex, and the following averaged 24-h profile maternal capillary blood glucose values: preprandial, 1-h postprandial, and 2-h postprandial.

RESULTS

No difference was found between the two groups with respect to fetal lean body mass parameters; the factors that contributed significantly and most frequently were gestational age and fetal sex (male). With respect to fetal fat body mass, all the measurements were significantly higher in group 1 than in group 2. In all instances, the significantly contributing factors were gestational age and maternal 1-h postprandial glucose values, whereas another frequent contributor was prepregnancy BMI.

CONCLUSIONS

Our study suggests the possibility of using sonographically determined fetal fat and lean mass measurements as indicators of body composition. The assessment of these parameters, achievable in a noninvasive and reproducible fashion in pregnancies complicated by glucose intolerance, might enable the real-time detection of fetal overgrowth and disproportion, thus opening the possibility of exploring interventions to limit fetal fat accretion, birth weight, and potential resulting morbidity.

New and future diabetes therapies: are they safe during pregnancy?

Diabetes in pregnancy, whether the woman had diabetes prior to becoming pregnant or developed gestational diabetes, is associated with many complications and risks. In the first trimester, organogenesis can be disrupted by complications due to poor control of the mother's diabetes, leading to fetal malformations or perinatal mortality. Problems with glucose control in the remainder of the pregnancy can also have consequences for the child. These include macrosomia, shoulder dystocia, pre-eclampsia, hypoglycemia and an increased risk for obesity and diabetes in the future. Therefore, aggressive and prompt treatment of the high blood sugar levels, which cause these complications, is necessary. This review looks at the current treatments for pregnancies complicated by diabetes and evaluates the place of new and possible future treatments including diet, exercise, insulin, insulin analogs and oral and inhaled agents.

A reconsideration of the origins of the type 2 diabetes epidemic among Native Americans and the implications for intervention policy

Type 2 diabetes has reached epidemic proportions in many Native American communities in North America. The overwhelming majority of physicians, biomedical researchers, and medical ecologists continue to explain the astoundingly high prevalence rates of diabetes among Native Americans and other high prevalence populations in terms of yet-to-be-identified genetic factors. Recent experimental and epidemiological research, however, has brought to light an etiological alternative to the genetic-predisposition model. This body of research suggests that type 2 diabetes may result initially from fetal malnutrition and, in subsequent generations, be propagated via perturbations in the intrauterine environment. Native American populations at greatest risk for diabetes today are the ones most likely to have endured severe nutritional stress in their recent histories, thus experiencing the conditions that are most conducive to the diabetic developmental sequence. If further substantiated, the implications of the fetal-origin model of diabetes for diabetes intervention programs are profound.