First-trimester HbA1c in relation to plasma glucose concentrations in an oral glucose tolerance test at 12 to 16 weeks' gestation-a population-based study

BACKGROUND

Early-onset GDM often requires pharmacological treatment and is associated with adverse perinatal outcomes, but data is insufficient regarding the best methods to identify high-risk women requiring early GDM screening. The aim of this study was to analyze the diagnostic accuracy of HbA1c in the prediction of (1) plasma glucose concentrations > 90th percentile in an oral glucose tolerance test (OGTT) at 12-16 weeks' gestation; and (2) pharmacologically treated early- or late-onset GDM.

METHODS

HbA1c was measured at 8-14 weeks' gestation in a population-based cohort of 1394 Finnish women recruited for the Early Diagnosis of Diabetes in Pregnancy (EDDIE) study between 3/2013 and 12/2016. Information on maternal risk factors were collected at recruitment. Subsequently, a 2-hour 75 g OGTT was performed at 12-16 weeks' gestation (OGTT1), and if normal, repeated at 24-28 weeks' gestation (OGTT2). Early- and late-onset GDM were diagnosed using the same nationally endorsed cut-offs for fasting, 1 h- and 2 h-plasma glucose: ≥5.3, ≥ 10.0mmol/l, and/or ≥ 8.6mmol/l, respectively. In total, 52/1394 (3.7%) women required metformin or insulin treatment for GDM, including 39 women with early-onset GDM diagnosed at OGTT1 and 13 women with late-onset GDM diagnosed at OGTT2.

RESULTS

Maternal early-pregnancy HbA1c ≥ 35mmol/mol (≥ 5.4%) was the best cut-off to predict fasting or post-load plasma glucose > 90th percentile in OGTT1, but its diagnostic accuracy was low [AUC (95% CI) 0.65 (0.62 to 0.69), sensitivity 0.55 (0.49 to 0.60) and specificity 0.67 (0.64 to 0.70)] both alone and in combination with other maternal risk factors. However, HbA1c ≥ 35mmol/mol correlated positively with plasma glucose concentrations at all time points of OGTT1 and predicted pharmacologically treated GDM diagnosed at OGTT1 or OGTT2; AUC (95% CI) 0.75 (0.68 to 0.81), sensitivity 0.75 (0.61 to 0.86), specificity 0.64 (0.61 to 0.66).

CONCLUSIONS

In our population-based cohort, early-pregnancy HbA1c ≥ 35mmol/mol was positively associated with fasting and post-load plasma glucose concentrations in an OGTT at 12-16 weeks' gestation and predicted pharmacologically-treated early- and late-onset GDM, suggesting potential utility in first-trimester identification of women at high risk of severe GDM subtypes.

Large maternal waist circumference in relation to height is associated with high glucose concentrations in an early-pregnancy oral glucose tolerance test: A population-based study

INTRODUCTION

To explore the role of maternal anthropometric characteristics in early-pregnancy glycemia, we analyzed the associations and interactions of maternal early-pregnancy waist circumference (WC), height and pre-pregnancy body mass index (BMI) with plasma glucose concentrations in an oral glucose tolerance test (OGTT) at 12-16 weeks' gestation.

MATERIAL AND METHODS

A population-based cohort of 1361 pregnant women was recruited in South Karelia, Finland, from March 2013 to December 2016. All participants had their WC, weight, height, HbA_1c , and blood pressure measured at 8-14 weeks' gestation and subsequently underwent a 2-h 75-g OGTT, including assessment of fasting insulin concentrations, at 12-16 weeks' gestation. BMI (kg/m² ) was calculated using self-reported pre-pregnancy weight. Maternal WC ≥80 cm was defined as large. Maternal height ≥166 cm was defined as tall. Data on gestational diabetes treatment was extracted from hospital records.

RESULTS

In the total cohort, 901 (66%) of women had an early-pregnancy WC ≥80 cm, which was associated with higher early-pregnancy HbA_1c, higher concentrations of  fasting plasma glucose and serum insulin, higher post-load plasma glucose concentrations, higher HOMA-IR indices, higher blood pressure levels, and higher frequencies of pharmacologically treated gestational diabetes, than early-pregnancy WC <80 cm. Maternal height ≥166 cm was negatively associated with 1- and 2-h post-load plasma glucose concentrations. Waist-to-height ratio (WHtR) >0.5 was positively associated with both fasting and post-load plasma glucose concentrations at 12-16 weeks' gestation, even when adjusted for age, smoking, nulliparity, and family history of type 2 diabetes. The best cut-offs for WHtR (0.58 for 1-h plasma glucose, and 0.54 for 2-h plasma glucose) were better predictors of post-load glucose concentrations >90th percentile than the best cut-offs for BMI (28.1 kg/m² for 1-h plasma glucose, and 26.6 kg/m² for 2-h plasma glucose), with areas-under-the-curve (95% confidence interval) 0.73 (0.68-0.79) and 0.73 (0.69-0.77), respectively, for WHtR, and 0.68 (0.63-0.74) and 0.69 (0.65-0.74), respectively, for BMI.

CONCLUSIONS

In our population-based cohort, early-pregnancy WHtR >0.5 was positively associated with both fasting and post-load glucose concentrations at 12-16 weeks' gestation and performed better than BMI in the prediction of post-load glucose concentrations >90th percentile. Overall, our results underline the importance of evaluating maternal abdominal adiposity in gestational diabetes risk assessment.

Longitudinal Metabolic Profiling of Maternal Obesity, Gestational Diabetes, and Hypertensive Pregnancy Disorders

CONTEXT

Comprehensive assessment of metabolism in maternal obesity and pregnancy disorders can provide information about the shared maternal-fetal milieu and give insight into both maternal long-term health and intergenerational transmission of disease burden.

OBJECTIVE

To assess levels, profiles, and change in the levels of metabolic measures during pregnancies complicated by obesity, gestational diabetes (GDM), or hypertensive disorders.

DESIGN, SETTING AND PARTICIPANTS

A secondary analysis of 2 study cohorts, PREDO and RADIEL, including 741 pregnant women.

MAIN OUTCOME MEASURES

We assessed 225 metabolic measures by nuclear magnetic resonance in blood samples collected at median 13 [interquartile range (IQR) 12.4-13.7], 20 (IQR 19.3-23.0), and 28 (27.0-35.0) weeks of gestation.

RESULTS

Across all 3 time points women with obesity [body mass index (BMI) ≥ 30kg/m2] in comparison to normal weight (BMI 18.5-24.99 kg/m2) had significantly higher levels of most very-low-density lipoprotein-related measures, many fatty and most amino acids, and more adverse metabolic profiles. The change in the levels of most metabolic measures during pregnancy was smaller in obese than in normal weight women. GDM, preeclampsia, and chronic hypertension were associated with metabolic alterations similar to obesity. The associations of obesity held after adjustment for GDM and hypertensive disorders, but many of the associations with GDM and hypertensive disorders were rendered nonsignificant after adjustment for BMI and the other pregnancy disorders.

CONCLUSIONS

This study shows that the pregnancy-related metabolic change is smaller in women with obesity, who display metabolic perturbations already in early pregnancy. Metabolic alterations of obesity and pregnancy disorders resembled each other suggesting a shared metabolic origin.

Lifestyle and glycemic health 5 years postpartum in obese and non-obese high diabetes risk women

AIM

Women with prior gestational diabetes (GDM) are at increased diabetes risk. This study aimed to assess whether lifestyle is associated with glycemic health of high-risk women 5 years postpartum, taking into account the pre-pregnancy BMI.

METHODS

The RADIEL study enrolled before or in early pregnancy 720 women with pre-pregnancy BMI ≥ 30 kg/m² and/or prior GDM. The follow-up visit 5 years postpartum included questionnaires and measurements of anthropometrics, blood pressure, and physical activity (PA) as well as analyses of glucose metabolism, lipids, and inflammatory markers. We measured body composition (Inbody) and calculated a Healthy Food Intake Index (HFII) from Food Frequency Questionnaires (FFQ). ArmBand measured PA, sedentary time, and sleep. To take into account the diverse risk groups of GDM, we divided the women based on pre-pregnancy BMI over/under 30 kg/m².

RESULTS

Altogether 348 women attended the follow-up. The obese and non-obese women showed similar prevalence of glycemic abnormalities, 13% and 19% (p = 0.139). PA levels were higher among the non-obese women (p < 0.05), except for step count, and their HFII was higher compared to the obese women (p = 0.033). After adjusting for age, education, and GDM history, PA and HFII were associated with glycemic health only among obese women. When both lifestyle factors were in the same model, only PA remained significant. PA associated with other markers of metabolic health also among the non-obese women, excluding HbA1c.

CONCLUSION

Lifestyle 5 years postpartum was associated with better glycemic health only among the obese high-risk women. PA, however, is essential for the metabolic health of all high-risk women.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, http://www.clinicaltrials.com , NCT01698385.

Neonatal outcomes among offspring of obese women diagnosed with gestational diabetes mellitus in early versus late pregnancy

BACKGROUND

Maternal metabolic derangements associated with early pregnancy gestational diabetes may affect the fetus differently compared with gestational diabetes diagnosed later in pregnancy. The aim of this observational study was to assess neonatal outcomes according to timing of gestational diabetes diagnosis in obese women.

METHODS

Women ≥18 years of age with a pre-pregnancy body mass index ≥30 kg/m2 were grouped according to the results of a 75 g 2-h oral glucose tolerance test performed at 13.1 weeks of gestation and repeated at 23.4 weeks if normal at first testing. The main outcomes were birthweight and large for gestational age.

RESULTS

Out of 361 women, 164 (45.4%) were diagnosed with gestational diabetes, 133 (81.1%) of them in early pregnancy. The mean offspring birthweight was 3673 g (standard deviation (SD) 589 g) in the early and 3710 g (SD 552 g) in the late gestational diabetes group. In a multivariate logit model, the odds ratio for large for gestational age was 2.01 (95% CI: 0.39-10.39) in early compared with late gestational diabetes.

CONCLUSIONS

We observed no statistically significant differences in neonatal outcomes according to timing of gestational diabetes diagnosis. In addition to lack of power, early treatment of hyperglycemia may partly explain the results.

Oral glucose tolerance test results in early pregnancy: A Finnish population-based cohort study

AIMS

To analyze early-pregnancy oral glucose tolerance test (OGTT) results and differences between early- and late-pregnancy OGTT results in a population-based cohort.

METHODS

From 3/2013 to 12/2016, pregnant women in South Karelia, Finland, were invited to undergo a 2-hour 75 g OGTT at 12-16 weeks' gestation (OGTT1) and, if normal, repeat testing at 24-28 weeks (OGTT2). Early and late gestational diabetes (GDM) were diagnosed using the same nationally endorsed criteria (fasting [FPG], 1- or 2-hour plasma glucose ≥5.3, ≥10.0 or ≥8.6 mmol/L, respectively).

RESULTS

In OGTT1 (n = 1401), the mean (SD) FPG, 1- and 2-hour values were 4.85 (0.34), 6.63 (1.73) and 5.60 (1.28) mmol/L, respectively. Early GDM was diagnosed in 209 (14.9%). In OGTT2 (n = 1067), late GDM was diagnosed in 114 (10.6%). In women without GDM (n = 953), the mean FPG values were higher and post-load values lower in OGTT1 vs. OGTT2. No interaction effects of gestational timepoint and maternal BMI on OGTT results were detected, except for the 2-hour value. In women with late GDM, both mean FPG and post-load values were lower in OGTT1 vs. OGTT2. Results were similar employing the IADPSG GDM criteria.

CONCLUSIONS

Our findings suggest that gestational-age specific OGTT thresholds for early GDM diagnosis need to be generated.

Heterogeneity of gestational diabetes (GDM) and challenges in developing a GDM risk score

AIMS

Gestational diabetes (GDM) affects a growing number of women and identification of individuals at risk, e.g., with risk prediction models, would be important. However, the performance of GDM risk scores has not been optimal. Here, we assess the impact of GDM heterogeneity on the performance of two top-rated GDM risk scores.

METHODS

This is a substudy of the RADIEL trial-a lifestyle intervention study including women at high GDM risk. We assessed the GDM risk score by Teede and that developed by Van Leeuwen in our high-risk cohort of 510 women. To investigate the heterogeneity of GDM, we further divided the women according to GDM history, BMI, and parity. With the goal of identifying novel predictors of GDM, we further analyzed 319 women with normal glucose tolerance in the first trimester.

RESULTS

Both risk scores underestimated GDM incidence in our high-risk cohort. Among women with a BMI ≥ 30 kg/m² and/or previous GDM, 49.4% developed GDM and 37.4% received the diagnosis already in the first trimester. Van Leeuwen score estimated a 19% probability of GDM and Teede succeeded in risk identification in 61%. The lowest performance of the risk scores was seen among the non-obese women. Fasting plasma glucose, HbA_1c, and family history of diabetes were predictors of GDM in the total study population. Analysis of subgroups did not provide any further information.

CONCLUSIONS

Our findings suggest that the marked heterogeneity of GDM challenges the development of risk scores for detection of GDM.

Prevention of gestational diabetes with a prepregnancy lifestyle intervention - findings from a randomized controlled trial

Purpose

Lifestyle intervention studies performed during pregnancy have shown inconsistent results in relation to prevention of gestational diabetes mellitus (GDM). Therefore, the aim of this study was to assess the effect of an intervention initiated already before pregnancy in prevention of GDM in high-risk women.

Patients and methods

A randomized controlled trial was conducted in four Finnish maternity hospitals between the years 2008 and 2014. Altogether 228 high-risk women planning pregnancy were randomized to an intervention (n=116) or a control group (n=112). The risk factors were body mass index ≥30 kg/m² (n=46), prior GDM (n=120), or both (n=62), without manifest diabetes at study inclusion. Trained study nurses provided individualized lifestyle counseling every 3 months in addition to a group session with a dietician. The control group received standard antenatal care. GDM was defined as one or more pathological glucose values in a 75 g 2-hour oral glucose tolerance test, performed between 12 and 16 weeks of gestation and if normal repeated between 24 and 28 weeks of gestation.

Results

Within 12 months, 67% of the women (n=72) in the intervention group and 63% of the women (n=71) in the control group (p=0.84) became pregnant. The cumulative incidence of GDM among the women available for the final analyses was 60% (n=39/65) in the intervention group and 54% (n=34/63) in the control group (p=0.49). GDM was diagnosed already before 20 weeks of gestation in 60% (n=44/73) of the cases.

Conclusion

The preconceptional lifestyle intervention applied in the present study did not reduce the incidence of GDM.

Patient-reported pelvic floor symptoms 5 years after hysterectomy with or without prolapse surgery

OBJECTIVE

The aim of this study was to evaluate the effect of hysterectomy with or without concomitant prolapse surgery on subject-reported pelvic floor disorders (PFD) with a 5-year follow-up.

STUDY DESIGN

This prospective longitudinal study was carried out in two Finnish central hospitals among 286 women who had undergone hysterectomy for benign reasons. The presence of urinary incontinence, urinary frequency, feeling of vaginal bulging, constipation and anal incontinence was evaluated at baseline, 1 and 5 years postoperatively. Analysis was performed on 256 (895%) patients who answered at least one of the follow-up questionnaires.

RESULTS

Hysterectomy with concomitant native tissue prolapse surgery significantly reduced urinary incontinence, urinary frequency, constipation and the feeling of vaginal bulging, and the results were maintained over the following five years. Plain hysterectomy reduced urinary frequency and the feeling of vaginal bulging but did not relieve urinary incontinence. Hysterectomy had no effect on anal incontinence. The total subsequent prolapse and/or incontinence operation rate was 2,7%, and was higher among patients who underwent hysterectomy for pelvic organ prolapse.

CONCLUSIONS

During a 5-years follow-up a hysterectomy alone or with native tissue prolapse surgery did not worsen pelvic floor disorders.

Heterogeneity of gestational diabetes (GDM) and long-term risk of diabetes and metabolic syndrome: findings from the RADIEL study follow-up

AIMS

To assess the metabolic health of obese and non-obese women at high GDM risk 5 years postpartum.

METHODS

This is a secondary analysis of the 5-year follow-up of the RADIEL GDM prevention study including 333 women at high GDM risk (BMI ≥ 30 kg/m² and/or previous GDM). Five years postpartum metabolic health was assessed including anthropometric measurements, oral glucose tolerance test, lipid metabolism, and body composition as well as medical history questionnaires. For the analysis, we divided the women into four groups based on parity, BMI, and previous history of GDM.

RESULTS

Five years postpartum impaired glucose regulation (IFG, IGT, or diabetes) was diagnosed in 15% of the women; 3.6% had type 2 diabetes. The highest prevalence was observed among obese women with a history of GDM (26%), and the lowest prevalence (8%) among primiparous obese women (p = 0.021). At follow-up 25-39% of the obese women fulfilled the diagnostic criteria for the metabolic syndrome, in the non-obese group 11% (p < 0.001). This was associated with body fat percentage. The non-obese group, however, faced metabolic disturbances (IFG, IGT, diabetes, or metabolic syndrome) at a significantly lower BMI (p < 0.001). Among women who were non-obese before pregnancy, 5 years postpartum, the obesity prevalence based on BMI was 14% and based on body fat percentage 58%.

CONCLUSIONS

The prevalence of impaired glucose regulation and metabolic syndrome is high 5 years postpartum among women at high risk of GDM. There are high-risk women also among the non-obese, who develop metabolic derangements already at a lower BMI.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.com , NCT01698385.

Effects of a Lifestyle Intervention During Pregnancy and First Postpartum Year: Findings From the RADIEL Study

CONTEXT

Women with a history of gestational diabetes (GDM) have a sevenfold risk of developing type 2 diabetes.

OBJECTIVE

To assess the effects of a lifestyle intervention during pregnancy and first postpartum year on glucose regulation, weight retention, and metabolic characteristics among women at high GDM risk.

DESIGN

In the Finnish Gestational Diabetes Prevention study, trained study nurses provided lifestyle counseling in each trimester and 6 weeks, 6 months, and 12 months postpartum.

SETTING

Three maternity hospitals in the Helsinki area and one in Lappeenranta.

PATIENTS

In total, 269 women with previous GDM and/or a prepregnancy body mass index ≥30 kg/m2 were enrolled before 20 gestational weeks and allocated to either a control or an intervention group. This study includes the 200 participants who attended study visits 6 weeks and/or 12 months postpartum.

INTERVENTION

The lifestyle intervention followed Nordic diet recommendations and at least 150 minutes of moderate exercise was recommended weekly.

MAIN OUTCOME MEASURE

The incidence of impaired glucose regulation (impaired fasting glucose, impaired glucose tolerance, or type 2 diabetes) during the first postpartum year.

RESULTS

Impaired glucose regulation was present in 13.3% of the women in the control and in 2.7% in the intervention group [age-adjusted odds ratio, 0.18 (95% confidence interval, 0.05 to 0.65), P = 0.009] during the first postpartum year. There were no differences between the groups in weight retention, physical activity, or diet at 12 months postpartum.

CONCLUSIONS

A lifestyle intervention during pregnancy and the first postpartum year successfully reduced the incidence of postpartum impairment in glucose regulation.

A randomized lifestyle intervention preventing gestational diabetes: effects on self-rated health from pregnancy to postpartum

INTRODUCTION

The purpose was to examine the effects of a randomized lifestyle intervention on self-rated health from pregnancy to postpartum in participants at high risk for gestational diabetes mellitus.

METHODS

We included 266 women with a history of gestational diabetes and/or prepregnancy BMI ≥30 kg/m². The intervention group (n = 144) received individualized counseling on diet, physical activity, and weight management from trained nurses at six timepoints between the first trimester of pregnancy and 12 months postpartum, and met three times with a dietitian. The control group (n = 122) received standard antenatal care. We assessed self-rated health at the six timepoints by means of a single question with five response options ranging from good (1) to poor (5). Baseline-adjusted mean changes in self-rated health level were assessed with a mixed model for repeated measure methods.

RESULTS

The mean (SD) for self-rated health at baseline was 1.8 (0.8) in the intervention group and 2.1 (0.9) in the control group (p = 0.006). Self-rated health varied over time (time effect p < 0.001) and was the poorest in the third trimester. The sample indicated that self-rated health improved in the intervention group and deteriorated in the control group from the first trimester to 12 months postpartum, but the difference between the groups did not reach statistical significance (group effect p = 0.064).

DISCUSSION

The self-rated health level varied over time from the first trimester of pregnancy to 12 months postpartum in women at risk for gestational diabetes. Improving self-rated health among high-risk pregnant women through lifestyle intervention calls for further research.

The effect of pre-pregnancy lifestyle counselling on food intakes and association between food intakes and gestational diabetes in high-risk women: results from a randomised controlled trial

BACKGROUND

Healthy diets before and during pregnancy have been suggested to reduce the risk of gestational diabetes (GDM). Several lifestyle intervention studies for pregnant women have reported dietary improvements after counselling. However, evidence concerning the effect of counselling initiated before pregnancy on diets is limited.

METHODS

This randomised controlled study explored whether pre-pregnancy lifestyle counselling influenced food intakes, as well as whether changes in food intakes were associated with GDM. The participants comprised 75 women with prior GDM and/or a body mass index ≥ 30 kg m^-2 . Women were randomised into a control or an intervention group, and their food intakes were followed from pre-pregnancy to early pregnancy using a food frequency questionnaire. The control and intervention groups were combined to assess the association between changes in food intakes and GDM. The diagnosis of GDM was based on a 75-g oral glucose tolerance test conducted in the first and second trimester of pregnancy.

RESULTS

Pre-pregnancy lifestyle counselling showed no major overall effect on food intakes. The intake of low-fat cheese increased significantly in women who did not develop GDM compared to women who did after adjusting for potential confounders (P = 0.028). This association was not observed for regular-fat cheese.

CONCLUSIONS

The findings obtained in the present study suggest that an increased intake of low-fat but not regular-fat cheese between pre-pregnancy and early pregnancy is associated with a lower risk of GDM in high-risk women.

"The Burden of Pregnancy"; heavier for the heaviest? The changes in Health Related Quality of Life (HRQoL) assessed by the 15D instrument during pregnancy and postpartum in different body mass index groups: a longitudinal survey

INTRODUCTION

Only little information is available on health-related quality of life (HRQoL) and its changes during the course of a normal pregnancy. We studied changes in HRQoL in a pregnant population during pregnancy and until 1 year postpartum in different body mass index (BMI) groups.

MATERIAL AND METHODS

Seven hundred and fifty pregnant women attending the first ultrasound examination before gestational week 14 were invited to participate in a longitudinal, communal-based survey. The participants were divided into three groups according to their BMI; <25, 25-29.9, and ≥30 kg/m² . The women were asked to fill in questionnaires assessing HRQoL (15D), depressive symptoms (Edinburgh Depression Scale, EPDS), medical, obstetric and socioeconomic status at baseline. HRQoL and EPDS were re-assessed at 30 weeks of gestation, and 6 weeks, 3 and 12 months postpartum.

RESULTS

Of the invited 750 mothers, 325 (43%) returned the questionnaires and at least one follow-up questionnaire. At baseline, mean 15D scores decreased with increasing BMI but the difference was not statistically significant when adjusted for age, educational attainment, parity or EPDS-scores (0.929, 0.921 and 0.916, p = 0.16). During the course of pregnancy, the HRQoL of all women decreased but this decrease was significantly greater in the obese group (-0.088; 95% CI -0.110 to -0.065) than in the other groups [-0.054 (95% CI -0.062 to -0.045) and -0.051 (95% CI -0.068 to -0.033), p = 0.019]. Within 3 months postpartum the mean HRQoL recovered in all BMI groups to baseline levels, irrespective of the mode of delivery or pregnancy-related complications.

CONCLUSION

The burden of pregnancy is heavier for the heaviest.

Interaction between rs10830963 polymorphism in MTNR1B and lifestyle intervention on occurrence of gestational diabetes

AIMS/HYPOTHESIS

The aim of this study was to assess the interaction between melatonin receptor 1B gene (MTNR1B) rs10830963 polymorphism and lifestyle intervention during pregnancy on occurrence of gestational diabetes mellitus (GDM) in high-risk women.

METHODS

This is a secondary analysis of the randomised controlled gestational diabetes prevention trial 'RADIEL', conducted between 2008 and 2014 in four maternity hospitals in southern Finland. A total of 226 women with a history of GDM and/or a pre-pregnancy BMI ≥ 30 kg/m(2) were enrolled at <20 weeks of gestation (mean 13 weeks) and randomised into an intervention group receiving counselling on diet, physical activity and weight control and a control group receiving standard antenatal care. The main outcome was incidence of GDM, defined as one or more pathological glucose values in a standard 75 g 2-h OGTT. The MTNR1B rs10830963 was genotyped for further analyses.

RESULTS

No significant differences were found in the genotype distribution between the intervention and the control group. A significant interaction was observed between the rs10830963 genotypes and the lifestyle intervention on age-adjusted occurrence of gestational diabetes (p = 0.038). Among women homozygous for the C allele of rs10830963, the OR for GDM was significantly lower in the intervention group than in the control group (OR 0.16 [95% CI 0.03, 0.85], p = 0.014). This difference was not seen in women heterozygous (OR 0.88 [95% CI 0.32, 2.41], p = 0.798) or homozygous (OR 2.25 [95% CI 0.34, 14.69], p = 0.384) for the risk allele G.

CONCLUSIONS/INTERPRETATION

In women at high risk of GDM, only those not carrying the risk allele G benefited from the lifestyle intervention. Our results indicate that certain genetic risk variants may modify the effectiveness of lifestyle interventions. This may provide important information when planning GDM prevention studies in the future.

Healthy Food Intake Index (HFII) - Validity and reproducibility in a gestational-diabetes-risk population

Background

The aim was to develop and validate a food-based diet quality index for measuring adherence to the Nordic Nutrition Recommendations (NNR) in a pregnant population with high risk of gestational diabetes (GDM).

Methods

This study is a part of the Finnish Gestational Diabetes Prevention Study (RADIEL), a lifestyle intervention conducted between 2008 and 2014. The 443 pregnant participants (61 % of those invited), were either obese or had a history of GDM. Food frequency questionnaires collected at 1st trimester served for composing the HFII; a sum of 11 food groups (available score range 0–17) with higher scores reflecting higher adherence to the NNR.

Results

The average HFII of the participants was 10.2 (SD 2.8, range 2–17). Factor analysis for the HFII component matrix revealed three factors that explained most of the distribution (59 %) of the HFII. As an evidence of the component relevance 9 out of 11 of the HFII components independently contributed to the total score (item-rest correlation coefficients <0.31). Saturated fatty acids, monounsaturated fatty acids, polyunsaturated fatty acids, sucrose, and fiber intakes (among other nutrients) showed linearity across the HFII categories (P ≤ 0.030 for all nutrients tested); the higher the HFII, the closer the nutrient intake to the recommended intake level. Educational attainment (P = 0.0045), BMI (P = 0.0098), smoking (P = 0.007), and leisure time physical exercise (P = 0.038) showed linearity across the HFII categories. Intra-class correlation coefficient for the HFII was 0.85 (CI 0.79, 0.90).

Conclusions

The HFII components reflect the food guidelines of the NNR, intakes of relevant nutrients, and characteristics known to vary with diet quality. It largely ignores energy intake, its components have independent contribution to the HFII, and it exhibits reproducibility. The main shortcomings are absence of red and processed meat component, and the validation in a selected study population. It is suitable for ranking participants according to the adherence to the NNR in pregnant women at high risk of GDM.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3303-7) contains supplementary material, which is available to authorized users.

Heterogeneity of maternal characteristics and impact on gestational diabetes (GDM) risk-Implications for universal GDM screening?

OBJECTIVE

To study the incidence of gestational diabetes mellitus (GDM) in relation to phenotypic characteristics and gestational weight gain (GWG) among women at high risk for GDM.

MATERIALS AND METHODS

This is a secondary analysis of a GDM prevention study (RADIEL), a randomized controlled trial conducted in Finland. 269 women with a history of GDM and/or a pre-pregnancy body mass index (BMI) ≥ 30 kg/m(2) were enrolled before 20 weeks of gestation and divided into four groups according to parity, BMI and previous history of GDM. The main outcome was incidence of GDM.

RESULTS

There was a significant difference in incidence of GDM between the groups (p < 0.001). Women with a history of GDM and BMI <30 kg/m(2) showed the highest incidence (35.9%). At baseline they had fewer metabolic risk factors and by the second trimester they gained more weight. There was no interaction between GWG and GDM outcome and no significant difference in the prevalence of diabetes-associated antibodies.

CONCLUSION

Despite a healthier metabolic profile at baseline the non-obese women with a history of GDM displayed a markedly higher cumulative incidence of GDM. GWG and the presence of diabetes-associated antibodies were not associated with GDM occurrence among these high-risk women. Key message Despite a healthier metabolic profile at baseline the non-obese women with previous gestational diabetes mellitus display a markedly higher cumulative incidence of gestational diabetes mellitus.

Risk of Pregnancy Complications in Relation to Maternal Prepregnancy Body Mass Index: Population-Based Study from Finland 2006-10

BACKGROUND

Overweight and obesity are well-known risk factors for several pregnancy-related complications, but the nature of the association between maternal adiposity and these complications has been less studied. The objective of the present study was to examine the shape and the magnitude of the association between maternal prepregnancy body mass index and the risk of gestational diabetes, pre-eclampsia of different severity, gestational hypertension, and obstetric cholestasis among Finnish primiparae women.

METHODS

Data on all primiparae women who delivered a singleton newborn in Finland between 2006 and 2010 were identified from the Finnish Medical Birth Register and the Finnish Hospital Discharge Register (n = 119 485). Associations were analysed using restricted cubic spline regression and logistic regression models.

RESULTS

There was a nonlinear dose-dependent association between body mass index and the risk of gestational diabetes, pre-eclampsia, and gestational hypertension, and the risk was increased already among normal weight primiparae women. However, in the presence of pre-existing hypertension or diabetes body mass index was not associated with the risk of pre-eclampsia.

CONCLUSIONS

Efforts to reduce prepregnancy overweight and obesity need to be intensified, and also, measures to better identify those normal weight women who are at increased risk of gestational diabetes, pre-eclampsia and gestational hypertension should be developed.

Gestational Diabetes Mellitus Can Be Prevented by Lifestyle Intervention: The Finnish Gestational Diabetes Prevention Study (RADIEL): A Randomized Controlled Trial

OBJECTIVE

To assess whether gestational diabetes mellitus (GDM) can be prevented by a moderate lifestyle intervention in pregnant women who are at high risk for the disease.

RESEARCH DESIGN AND METHODS

Two hundred ninety-three women with a history of GDM and/or a prepregnancy BMI of ≥30 kg/m(2) were enrolled in the study at <20 weeks of gestation and were randomly allocated to the intervention group (n = 155) or the control group (n = 138). Each subject in the intervention group received individualized counseling on diet, physical activity, and weight control from trained study nurses, and had one group meeting with a dietitian. The control group received standard antenatal care. The diagnosis of GDM was based on a 75-g, 2-h oral glucose tolerance test at 24-28 weeks of gestation.

RESULTS

A total of 269 women were included in the analyses. The incidence of GDM was 13.9% in the intervention group and 21.6% in the control group ([95% CI 0.40-0.98%]; P = 0.044, after adjustment for age, prepregnancy BMI, previous GDM status, and the number of weeks of gestation). Gestational weight gain was lower in the intervention group (-0.58 kg [95% CI -1.12 to -0.04 kg]; adjusted P = 0.037). Women in the intervention group increased their leisure time physical activity more and improved their dietary quality compared with women in the control group.

CONCLUSIONS

A moderate individualized lifestyle intervention reduced the incidence of GDM by 39% in high-risk pregnant women. These findings may have major health consequences for both the mother and the child.

Nutrient intake of pregnant women at high risk of gestational diabetes

Background

The prevalence of gestational diabetes (GDM) has been increasing along with the obesity pandemic. It is associated with pregnancy complications and a risk of type 2 diabetes.

Objective

To study nutrient intake among pregnant Finnish women at increased risk of GDM due to obesity or a history of GDM.

Design

Food records from obese women or women with GDM history (n=394) were examined at baseline (≤20 weeks of pregnancy) of the Finnish Gestational Diabetes Prevention Study.

Results

The pregnant women had a mean fat intake of 33 en% (SD 7), saturated fatty acids (SFA) 12 en% (SD 3), and carbohydrate 46 en% (SD 6). Sucrose intake among pregnant women with GDM history was 7 en% (SD 3), which was different from the intake of the other pregnant women, 10 en% (SD 4) (p<0.001). Median intakes of folate and vitamins A and D provided by food sources were below the Finnish national nutrition recommendation, but, excluding vitamin A, supplements raised the total intake to the recommended level. The frequency of use of dietary supplements among pregnant women was 77%.

Conclusions

The observed excessive intake of SFA and low intake of carbohydrates among women at high risk of GDM may further increase their risk of GDM. A GDM history, however, seems to reduce sucrose intake in a future pregnancy. Pregnant women at high risk of GDM seem to have insufficient intakes of vitamin D and folate from food and thus need supplementation, which most of them already take.

Elevated serum squalene and cholesterol synthesis markers in pregnant obese women with gestational diabetes mellitus

We examined serum cholesterol synthesis and absorption markers and their association with neonatal birth weight in obese pregnancies affected by gestational diabetes mellitus (GDM). Pregnant women at risk for GDM (BMI >30 kg/m²) were enrolled from maternity clinics in Finland. GDM was determined from the results of an oral glucose tolerance test. Serum samples were collected at six time-points, one in each trimester of pregnancy, and at 6 weeks, 6 months, and 12 months postpartum. Analysis of serum squalene and noncholesterol sterols by gas-liquid chromatography revealed that in subjects with GDM (n = 22), the serum Δ8-cholestenol concentration and lathosterol/sitosterol ratio were higher (P < 0.05) than in the controls (n = 30) in the first trimester, reflecting increased cholesterol synthesis. Also, subjects with GDM had an increased ratio of squalene to cholesterol (100 × μmol/mmol of cholesterol) in the second (11.5 ± 0.5 vs. 9.1 ± 0.5, P < 0.01) and third (12.1 ± 0.8 vs. 10.0 ± 0.7, P < 0.05) trimester. In GDM, the second trimester maternal serum squalene concentration correlated with neonatal birth weight (r = 0.70, P < 0.001). In conclusion, in obesity, GDM associated with elevated serum markers of cholesterol synthesis. Correlation of maternal serum squalene with neonatal birth weight suggests a potential contribution of maternal cholesterol synthesis to newborn weight in GDM.

Quality of life and pelvic floor dysfunction symptoms after hysterectomy with or without pelvic organ prolapse

OBJECTIVE

To assess the effect of hysterectomy with or without pelvic organ prolapse (POP) on health-related quality of life (HRQoL) and pelvic floor disorders.

STUDY DESIGN

Prospective clinical study at two central hospitals in Finland. During one year 322 women underwent elective hysterectomy for benign conditions with or without vaginal wall repair. The study population was divided in two groups, patients with and without POP. The HRQoL questionnaires RAND-36 and 15D, and questionnaires assessing urinary and bowel dysfunction symptoms were obtained preoperatively and 12 months postoperatively. POP was defined as the descent of apical, anterior or posterior compartment of vaginal wall grade ≥2 in the Baden-Walker classification at any site. Main outcome measures were HRQoL, improvement of symptoms and de novo symptoms.

RESULTS

At baseline the mean 15D score of all patients was lower than that of the age-standardized population sample (p<0.001). At one year postoperatively, the mean 15D score of the patients had improved (p=0.001), this resulting mainly on dimensions of excretion (voiding and defecation), usual activities, discomfort and symptom, distress, vitality and sexual activity. HRQoL improved especially in patients with POP. They reported improvement of symptoms in urinary incontinence, urinary frequency, constipation and sense of bulging but surgery had no effect on anal incontinence. Patients without POP reported improvement in pain dimension, urinary frequency and feeling of bulging. Urinary incontinence was the most common (15.4% and 13.8%) de novo symptom in both groups.

CONCLUSIONS

Hysterectomy with or without concomitant pelvic organ prolapse surgery improves health-related quality of life and reduces pelvic floor symptoms in one-year follow-up.

Prevention of gestational diabetes through lifestyle intervention: study design and methods of a Finnish randomized controlled multicenter trial (RADIEL)

BACKGROUND

Maternal overweight, obesity and consequently the incidence of gestational diabetes are increasing rapidly worldwide. The objective of the study was to assess the efficacy and cost-effectiveness of a combined diet and physical activity intervention implemented before, during and after pregnancy in a primary health care setting for preventing gestational diabetes, later type 2 diabetes and other metabolic consequences.

METHODS

RADIEL is a randomized controlled multi-center intervention trial in women at high risk for diabetes (a previous history of gestational diabetes or prepregnancy BMI ≥30 kg/m2). Participants planning pregnancy or in the first half of pregnancy were parallel-group randomized into an intervention arm which received lifestyle counseling and a control arm which received usual care given at their local antenatal clinics. All participants visited a study nurse every three months before and during pregnancy, and at 6 weeks, 6 and 12 months postpartum. Measurements and laboratory tests were performed on all participants with special focus on dietary and exercise habits and metabolic markers.Of the 728 women [mean age 32.5 years (SD 4.7); median parity 1 (range 0-9)] considered to be eligible for the study 235 were non-pregnant and 493 pregnant [mean gestational age 13 (range 6 to 18) weeks] at the time of enrollment. The proportion of nulliparous women was 29.8% (n = 217). Out of all participants, 79.6% of the non-pregnant and 40.4% of the pregnant women had previous gestational diabetes and 20.4% of the non-pregnant and 59.6% of the pregnant women were recruited because of a prepregnancy BMI ≥30 kg/m2. Mean BMI at first visit was 30.1 kg/m2 (SD 6.2) in the non-pregnant and 32.7 kg/m2 (SD 5.6) in the pregnant group.

DISCUSSION

To our knowledge, this is the first randomized lifestyle intervention trial, which includes, besides the pregnancy period, both the prepregnancy and the postpartum period. This study design also provides an opportunity to focus upon the health of the next generation. The study is expected to produce novel information on the optimal timing and setting of interventions and for allocating resources to prevent obesity and diabetes in women of reproductive age.

The relationship between clinical parameters and health-related quality of life as measured by the 15D in incontinent women before and after treatment

BACKGROUND

The purpose of this study was to correlate the clinical parameters with a health-related quality of life (HRQoL) measure and to describe the change of HRQoL caused by treatment and its modifying factors among urinary incontinent women.

METHODS

Eighty-two incontinent women, referred to a tertiary gynecologic department, underwent clinical evaluation to establish diagnosis and severity of urinary incontinence (UI) and completed the generic 15D HRQoL instrument. Sixty-nine women were re-evaluated 13 months after treatment.

RESULTS

Compared to age-matched female general population, the HRQoL of urinary incontinent women was significantly lower. Urge or mixed incontinence impairs HRQoL more than stress incontinence. The 15D scores correlated poorly with urodynamics, frequency/volume chart findings, and the amount of urine leakage. Among patients with stress UI (SUI), the HRQoL after treatment was the same as in the age-matched general female population. Among women with urge or mixed UI, the HRQoL improved significantly after treatment but did not reach the HRQoL level of women with SUI at baseline. In stepwise regression analysis, lower the 15D score at baseline and bigger the decrease in urine leakage, greater was the change in HRQoL for the better.

CONCLUSION

There was a modest correlation of incontinence severity measures with quality of life impairment. The challenge for the future will be to improve the success of treatment for women with urge UI. The generic 15D appears to be sensitive to detect change in HRQoL due to treatment of UI women.

Is physical activity influenced by urinary incontinence?

OBJECTIVE

To evaluate physical activity among urinary incontinent women seeking treatment and to assess the change of physical activity after treatment.

DESIGN

Part of a prospective observational intervention study to examine the factors influencing the severity of urinary incontinence.

SETTING

Tampere University Hospital-referral unit.

POPULATION

Eighty-two urinary incontinent women were evaluated in the baseline and 69 (84%) one year (mean 13 months, range 6-21) after treatment.

METHODS

Physical activity was measured by self-report questionnaire and electronic motion sensor: Caltrac accelerometer worn by women for one week. The diagnosis and severity of urinary incontinence was estimated on the basis of urodynamics, pad test, diary and incontinence-specific quality of life measures. Treatment outcome was assessed according to objective parameters and patients satisfaction.

MAIN OUTCOME MEASURES

Physical activity at work, leisure and sport expressed in MET (metabolic unit) and kilocalories, change in physical activity after treatment.

RESULTS

Twenty-one (25.6%) of all women reported exercise of more than three times per week. Incontinent women with the highest leisure time activity > or =6 MET (n= 23, above 75th centile) were younger; they had less body mass index and greater urine leakage than others. One year after treatment, there was no change in any parameters of physical activities. Also exercise habits among women who were completely dry (n= 37) after treatment were not changed.

CONCLUSION

Urinary incontinent women who seek treatment are as physically active as the normal population. Even after successful incontinence treatment, exercise habits do not change.

Do objective urodynamic or clinical findings determine impact of urinary incontinence or its treatment on quality of life?

OBJECTIVES

To correlate the clinical and urodynamic parameters with two measures of incontinence-specific quality of life (QOL), to describe the changes in those measures after treatment, and to explore the factors determining these changes.

METHODS

A total of 82 incontinent women (mean age 52 years, range 28 to 80) underwent urodynamics testing and a 48-hour pad test. They also completed the frequency/volume chart, estimated the degree of bother from urinary incontinence using the visual analog scale (VAS), and completed a validated QOL instrument--the Urinary Incontinence Severity Score (UISS). Sixty-nine women were re-evaluated 13 months (range 6 to 21) after treatment.

RESULTS

A greater degree of disability from urinary incontinence as measured by the VAS correlated with a lower maximal urethral closure pressure (r = -0.29, P <0.01), greater detrusor pressure (r = 0.30, P <0.05), and amount of urine leakage (r = 0.46, P <0.001). The UISS correlated poorly with the urodynamic and frequency/volume chart findings. A greater amount of urine leakage was the best predictor of QOL impairment as measured by the UISS (beta 0.25; P = 0.034). The change in urine leakage best predicted the change in the UISS (beta 0.30; P = 0.024) and the change in the VAS (beta 0.48; P = 0.001).

CONCLUSIONS

The response to the question "How bothered are you by incontinence at this moment?" best reflects the severity of urinary incontinence measured objectively. Urodynamic parameters correlated poorly with incontinence-specific QOL measure. Of the clinical objective measures of the severity of urinary incontinence, the amount of leakage in the pad test was the best, although modest, predictor of QOL impairment. The change in urine leakage best predicted the change in QOL scores and VAS 1 year after beginning treatment.

Visual analogue scale, urinary incontinence severity score and 15 D--psychometric testing of three different health-related quality-of-life instruments for urinary incontinent women

OBJECTIVE

The purpose of this study is psychometric assessment of disease-specific questionnaire, Urinary Incontinence Severity Score (UISS) and Visual Analogue Scale (VAS) in urinary incontinent women. We also investigated functional relationship between UISS, VAS and 15D-valid, generic health-related quality-of-life (HRQoL) instrument.

MATERIALS AND METHODS

Eighty-two incontinent female patients were recruited for the study that included baseline investigation and re-evaluation 13 months (range 6-21 months) after treatment. Twenty-nine control women who had urinary incontinence but were not bothered by it completed the HRQoL measurements.

RESULTS

Internal consistency and content validity of UISS was good. Both measures UISS and VAS were reproducible, Spearman's rank correlation between test-retest were 0.88 and 0.85 respectively. The control women's UISS, 15D and VAS scores were significantly lower than the patient's scores (p<0.001, Mann-Whitney U test) which proves to be a good discriminant. The changes in pad test correlated moderately well with those in the VAS and UISS. The UISS, VAS and 15D in the improved group had responsiveness (Guyatt's) statistics: 1.48, 1.74 and -0.80 respectively.

CONCLUSION

The UISS and VAS proved to be valid, reproducible and responsive to treatment for UI women. The functionality of the 15D was good but it demonstrated less sensitivity to changes after treatment.