Periodic mobile application (eMOM) with self-tracking of glucose and lifestyle improves treatment of diet-controlled gestational diabetes without human guidance: a randomized controlled trial

BACKGROUND

Digitalization with minimal human resources could support self-management among women with gestational diabetes and improve maternal and neonatal outcomes.

OBJECTIVE

This study aimed to investigate if a periodic mobile application (eMOM) with wearable sensors improves maternal and neonatal outcomes among women with diet-controlled gestational diabetes without additional guidance from healthcare personnel.

STUDY DESIGN

Women with gestational diabetes were randomly assigned in a 1:1 ratio at 24 to 28 weeks' gestation to the intervention or the control arm. The intervention arm received standard care in combination with use of the periodic eMOM, whereas the control arm received only standard care. The intervention arm used eMOM with a continuous glucose monitor, an activity tracker, and a food diary 1 week/month until delivery. The primary outcome was the change in fasting plasma glucose from baseline to 35 to 37 weeks' gestation. Secondary outcomes included capillary glucose, weight gain, nutrition, physical activity, pregnancy complications, and neonatal outcomes, such as macrosomia.

RESULTS

In total, 148 women (76 in the intervention arm, 72 in the control arm; average age, 34.1±4.0 years; body mass index, 27.1±5.0 kg/m2) were randomized. The intervention arm showed a lower mean change in fasting plasma glucose than the control arm (difference, -0.15 mmol/L vs -2.7 mg/mL; P=.022) and lower capillary fasting glucose levels (difference, -0.04 mmol/L vs -0.7 mg/mL; P=.002). The intervention arm also increased their intake of vegetables (difference, 11.8 g/MJ; P=.043), decreased their sedentary behavior (difference, -27.3 min/d; P=.043), and increased light physical activity (difference, 22.8 min/d; P=.009) when compared with the control arm. In addition, gestational weight gain was lower (difference, -1.3 kg; P=.015), and there were less newborns with macrosomia in the intervention arm (difference, -13.1 %; P=.036). Adherence to eMOM was high (daily use >90%), and the usage correlated with lower maternal fasting (P=.0006) and postprandial glucose levels (P=.017), weight gain (P=.028), intake of energy (P=.021) and carbohydrates (P=.003), and longer duration of the daily physical activity (P=.0006). There were no significant between-arm differences in terms of pregnancy complications.

CONCLUSION

Self-tracking of lifestyle factors and glucose levels without additional guidance improves self-management and the treatment of gestational diabetes, which also benefits newborns. The results of this study support the use of digital self-management and education tools in maternity care.

Associations Between Sedentary Time, Physical Activity, and Cardiovascular Health in 6-Year-Old Children Born to Mothers With Increased Cardiometabolic Risk

PURPOSE

To assess associations between sedentary time (ST), physical activity (PA), and cardiovascular health in early childhood.

METHOD

Cross-sectional study including 160 children (age 6.1 y [SD 0.5], 86 boys, 93 maternal body mass index ≥ 30 kg/m2, and 73 gestational diabetes) assessed for pulse wave velocity, echocardiography, ultra-high frequency 48-70 MHz vascular ultrasound, and accelerometery.

RESULTS

Boys had 385 (SD 53) minutes per day ST, 305 (SD 44) minutes per day light PA, and 81 (SD 22) minutes per day moderate to vigorous PA (MVPA). Girls had 415 (SD 50) minutes per day ST, 283 (SD 40) minutes per day light PA, and 66 (SD 19) minutes per day MVPA. In adjusted analyses, MVPA was inversely associated with resting heart rate (β = -6.6; 95% confidence interval, -12.5 to -0.7) and positively associated with left ventricular mass (β = 6.8; 1.4-12.3), radial intima-media thickness (β = 11.4; 5.4-17.5), brachial intima-media thickness (β = 8.0; 2.0-14.0), and femoral intima-media thickness (β = 1.3; 0.2-2.3). MVPA was inversely associated with body fat percentage (β = -3.4; -6.6 to -0.2), diastolic blood pressure (β = -0.05; -0.8 to -0.1), and femoral (β = -18.1; -32.4 to -0.8) and radial (β = -13.4; -24.0 to -2.9) circumferential wall stress in boys only. ST and pulse wave velocity showed no significant associations.

CONCLUSIONS

In young at-risk children, MVPA is associated with cardiovascular remodeling, partly in a sex-dependant way, likely representing physiological adaptation, but ST shows no association with cardiovascular health in early childhood.

Early ascending growth is associated with maternal lipoprotein profile during mid and late pregnancy and in cord blood

INTRODUCTION

Intrauterine conditions and accelerating early growth are associated with childhood obesity. It is unknown, whether fetal programming affects the early growth and could alterations in the maternal-fetal metabolome be the mediating mechanism. Therefore, we aimed to assess the associations between maternal and cord blood metabolite profile and offspring early growth.

METHODS

The RADIEL study recruited 724 women at high risk for gestational diabetes mellitus (GDM) BMI ≥ 30 kg/m2 and/or prior GDM) before or in early pregnancy. Blood samples were collected once in each trimester, and from cord. Metabolomics were analyzed by targeted nuclear magnetic resonance (NMR) technique. Following up on offsprings' first 2 years growth, we discovered 3 distinct growth profiles (ascending n = 80, intermediate n = 346, and descending n = 146) by using latent class mixed models (lcmm).

RESULTS

From the cohort of mother-child dyads with available growth profile data (n = 572), we have metabolomic data from 232 mothers from 1st trimester, 271 from 2nd trimester, 277 from 3rd trimester and 345 from cord blood. We have data on 220 metabolites in each trimester and 70 from cord blood. In each trimester of pregnancy, the mothers of the ascending group showed higher levels of VLDL and LDL particles, and lower levels of HDL particles (p < 0.05). When adjusted for gestational age, birth weight, sex, delivery mode, and maternal smoking, there was an association with ascending profile and 2nd trimester total cholesterol in HDL2, 3rd trimester total cholesterol in HDL2 and in HDL, VLDL size and ratio of triglycerides to phosphoglycerides (TG/PG ratio) in cord blood (p ≤ 0.002).

CONCLUSION

Ascending early growth was associated with lower maternal total cholesterol in HDL in 2nd and 3rd trimester, and higher VLDL size and more adverse TG/PG ratio in cord blood.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, http://www.

CLINICALTRIALS

com , NCT01698385.

Metabolomic Profiles of Nonobese and Obese Women With Gestational Diabetes

CONTEXT

In non-pregnant population, nonobese individuals with obesity-related metabolome have increased risk for type 2 diabetes and cardiovascular diseases. The risk of these diseases is also increased after gestational diabetes.

OBJECTIVE

This work aimed to examine whether nonobese (body mass index [BMI] < 30) and obese (BMI ≥ 30) women with gestational diabetes mellitus (GDM) and obese non-GDM women differ in metabolomic profiles from nonobese non-GDM controls.

METHODS

Levels of 66 metabolic measures were assessed in early (median 13, IQR 12.4-13.7 gestation weeks), and across early, mid (20, 19.3-23.0), and late (28, 27.0-35.0) pregnancy blood samples in 755 pregnant women from the PREDO and RADIEL studies. The independent replication cohort comprised 490 pregnant women.

RESULTS

Nonobese and obese GDM, and obese non-GDM women differed similarly from the controls across early, mid, and late pregnancy in 13 measures, including very low-density lipoprotein-related measures, and fatty acids. In 6 measures, including fatty acid (FA) ratios, glycolysis-related measures, valine, and 3-hydroxybutyrate, the differences between obese GDM women and controls were more pronounced than the differences between nonobese GDM or obese non-GDM women and controls. In 16 measures, including HDL-related measures, FA ratios, amino acids, and inflammation, differences between obese GDM or obese non-GDM women and controls were more pronounced than the differences between nonobese GDM women and controls. Most differences were evident in early pregnancy, and in the replication cohort were more often in the same direction than would be expected by chance alone.

CONCLUSION

Differences between nonobese and obese GDM, or obese non-GDM women and controls in metabolomic profiles may allow detection of high-risk women for timely targeted preventive interventions.

Comprehensive self-tracking of blood glucose and lifestyle with a mobile application in the management of gestational diabetes: a study protocol for a randomised controlled trial (eMOM GDM study)

INTRODUCTION

Gestational diabetes (GDM) causes various adverse short-term and long-term consequences for the mother and child, and its incidence is increasing globally. So far, the most promising digital health interventions for GDM management have involved healthcare professionals to provide guidance and feedback. The principal aim of this study is to evaluate the effects of comprehensive and real-time self-tracking with eMOM GDM mobile application (app) on glucose levels in women with GDM, and more broadly, on different other maternal and neonatal outcomes.

METHODS AND ANALYSIS

This randomised controlled trial is carried out in Helsinki metropolitan area. We randomise 200 pregnant women with GDM into the intervention and the control group at gestational week (GW) 24-28 (baseline, BL). The intervention group receives standard antenatal care and the eMOM GDM app, while the control group will receive only standard care. Participants in the intervention group use the eMOM GDM app with continuous glucose metre (CGM) and activity bracelet for 1 week every month until delivery and an electronic 3-day food record every month until delivery. The follow-up visit after intervention takes place 3 months post partum for both groups. Data are collected by laboratory blood tests, clinical measurements, capillary glucose measures, wearable sensors, air displacement plethysmography and digital questionnaires. The primary outcome is fasting plasma glucose change from BL to GW 35-37. Secondary outcomes include, for example, self-tracked capillary fasting and postprandial glucose measures, change in gestational weight gain, change in nutrition quality, change in physical activity, medication use due to GDM, birth weight and fat percentage of the child.

ETHICS AND DISSEMINATION

The study has been approved by Ethics Committee of the Helsinki and Uusimaa Hospital District. The results will be presented in peer-reviewed journals and at conferences.

TRIAL REGISTRATION NUMBER

NCT04714762.

Genetic risk of type 2 diabetes modifies the effects of a lifestyle intervention aimed at the prevention of gestational and postpartum diabetes

AIMS/HYPOTHESIS

The aim of this study was to assess the interaction between genetic risk and lifestyle intervention on the occurrence of gestational diabetes mellitus (GDM) and postpartum diabetes.

METHODS

The RADIEL study is an RCT aimed at prevention of GDM and postpartum diabetes through lifestyle intervention. Participants with a BMI ≥30 kg/m2 and/or prior GDM were allocated to intervention and control groups before pregnancy or in early pregnancy. The study visits took place every 3 months before pregnancy, once in each trimester, and at 6 weeks and 6 and 12 months postpartum. We calculated a polygenic risk score (PRS) based on 50 risk variants for type 2 diabetes.

RESULTS

Altogether, 516 participants provided genetic and GDM data. The PRS was associated with higher glycaemic levels (fasting glucose and/or HbA1c) and a lower insulin secretion index in the second and third trimesters and at 12 months postpartum, as well as with a higher occurrence of GDM and glycaemic abnormalities at 12 months postpartum (n = 356). There was an interaction between the PRS and lifestyle intervention (p=0.016 during pregnancy and p=0.024 postpartum) when analysing participants who did not have GDM at the first study visit during pregnancy (n = 386). When analysing women in tertiles according to the PRS, the intervention was effective in reducing the age-adjusted occurrence of GDM only among those with the highest genetic risk (OR 0.37; 95% CI 0.17, 0.82). The risk of glycaemic abnormalities at 12 months postpartum was reduced in the same group after adjusting additionally for BMI, parity, smoking and education (OR 0.35; 95% CI 0.13, 0.97).

CONCLUSIONS/INTERPRETATION

Genetic predisposition to diabetes modifies the response to a lifestyle intervention aimed at prevention of GDM and postpartum diabetes. This suggests that lifestyle intervention may benefit from being tailored according to genetic risk.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01698385.

Ultra-high frequency ultrasound delineated changes in carotid and muscular artery intima-media and adventitia thickness in obese early middle-aged women

Obesity is linked to increased arterial size, carotid intima-media thickness and arterial stiffness. The effects of obesity and body composition on muscular artery intima-media and adventitia thickness has previously not been established. The aim of this study was to explore associations between carotid and muscular artery wall layer thickness with body composition and cardiovascular risk factors in early middle-aged women. This is a cross-sectional study including 199 women aged 40±4 years. Arterial lumen (LD), intima-media (IMT) and adventitia thickness (AT) were measured from carotid, brachial and radial arteries using ultra-high frequency ultrasound (22-71 MHz). Women with obesity had increased IMT in carotid (0.47 vs 0.45 mm), brachial (0.19 vs 0.17 mm) and radial arteries (0.16 vs 0.15 mm) and increased brachial AT (0.14 vs 0.13 mm). In multiple regression models all arterial LD (β-range 0.02-0.03 mm/kg/m²), IMT (β-range 0.91-3.37 µm/kg/m²), AT (β-range 0.73-1.38 µm/kg/m²) were significantly associated with BMI. The IMT of all arteries were significantly associated with systolic blood pressure (β-range 0.36-0.85 µm/mmHg), attenuating the association between IMT and BMI (β-range 0.18-2.24 µm/kg/m²). Obese early middle-aged women have increased arterial intima media thickness and brachial artery adventitia thickness compared to non-obese counterparts. The association between BMI and intima-media thickness is partly mediated through blood pressure levels.

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.

Ascending Growth is Associated with Offspring Adiposity in Pregnancies Complicated with Obesity or Gestational Diabetes

CONTEXT

Early growth is associated with childhood adiposity, but the influence of lifestyle remains unknown.

OBJECTIVE

This work aimed to investigate the association of growth profiles from high-risk pregnancies with adiposity at age 5 years, taking into account lifestyle and several antenatal/postnatal exposures.

METHODS

This prospective cohort study.

INCLUDED

609 children born during the Finnish Gestational Diabetes Prevention Study (RADIEL), recruiting women with body mass index (BMI) greater than or equal to 30 and/or prior gestational diabetes mellitus (GDM) (2008-2013). Altogether 332 children attended the 5-year follow-up (2014-2017). Main outcome measures included growth profiles based on ponderal index (PI = weight/height3), investigated using latent class mixed models. Adiposity was assessed with anthropometrics and body composition (InBody720).

RESULTS

We identified 3 growth profiles: ascending (n = 82), intermediate (n = 351), and descending (n = 149). Children with ascending growth had a higher body fat percentage, ISO-BMI, and waist circumference (P < .05) at age 5 years. Ascending (β 4.09; CI, 1.60-6.58) and intermediate (β 2.27; CI, 0.50-4.03) profiles were associated with higher fat percentage, even after adjustment for age, sex, gestational age, diet, physical activity, education, and prepregnancy BMI. Similar associations existed with ISO-BMI. After adjusting for age and education, ascending growth was associated with prepregnancy BMI (odds ratio [OR] 1.06; CI, 1.01-1.12), primiparity (OR 3.07; CI, 1.68-5.62), cesarean delivery (OR 2.23; CI, 1.18-4.21), and lifestyle intervention (OR 2.56; CI, 1.44-4.57). However, meeting the intervention goals and exclusive breastfeeding for 3 months or more were associated with lower odds of ascending growth.

CONCLUSION

Accelerated early growth was associated with higher adiposity in 5-year-old children from high-risk pregnancies, even when adjusted for lifestyle. Reducing cesarean deliveries and promoting breastfeeding may be beneficial for postnatal growth.

Ideal Cardiovascular Health and Vascular Phenotype Associations in Mothers with Obesity and Their Six-Year-Old Children

BACKGROUND

Heredity and family-shared lifestyle contribute to cardiovascular risk, but the magnitude of their influence on arterial structure and function in early childhood is unknown. We aimed to assess associations between child and maternal ideal cardiovascular health, maternal subclinical atherosclerosis, and child arterial phenotype.

METHODS

Cross-sectional analysis of 201 mother-child pairs originating from the Finnish Gestational Diabetes Prevention Study (RADIEL) longitudinal cohort was done at child age 6.1 ± 0.5 years with assessments of ideal cardiovascular health (BMI, blood pressure, fasting glucose, total cholesterol, diet quality, physical activity, smoking), body composition, very-high frequency ultrasound of carotid arteries (25 and 35 MHz), and pulse wave velocity.

RESULTS

We found no association between child and maternal ideal cardiovascular health but report evidence of particular metrics correlations: total cholesterol (r=0.24, P=0.003), BMI (r=0.17, P=0.02), diastolic blood pressure (r=0.15, P=0.03), and diet quality (r=0.22, P=0.002). Child arterial phenotype was not associated with child or maternal ideal cardiovascular health. In the multivariable regression explanatory model adjusted for child sex, age, systolic blood pressure, lean body mass, and body fat percentage, child carotid intima-media thickness was independently associated only with maternal carotid intima-media thickness (0.1 mm increase [95% CI 0.05, 0.21, P=0.001] for each 1 mm increase in maternal carotid intima-media thickness). Children of mothers with subclinical atherosclerosis had decreased carotid artery distensibility (1.1 ± 0.2 vs 1.2 ± 0.2%/10 mmHg, P=0.01) and trend toward increased carotid intima-media thickness (0.37 ± 0.04 vs 0.35 ± 0.04 mm, P=0.06).

CONCLUSION

Ideal Cardiovascular Health metrics are heterogeneously associated in mother-child pairs in early childhood. We found no evidence of child or maternal Ideal Cardiovascular Health effect on child arterial phenotype. Maternal carotid intima-media thickness predicts child carotid intima-media thickness, but the underlying mechanisms remain unclear. Maternal subclinical atherosclerosis is associated with local carotid arterial stiffness in early childhood.

No effect of gestational diabetes or pre-gestational obesity on 6-year offspring left ventricular function-RADIEL study follow-up

AIMS

We aimed to investigate associations between pre-pregnancy obesity, gestational diabetes (GDM), offspring body composition, and left ventricular diastolic and systolic function in early childhood.

METHODS

This is an observational study, including 201 mother-child pairs originating from the Finnish Gestational Diabetes Prevention Study (RADIEL; 96 with GDM, 128 with pre-pregnancy obesity) with follow-up from gestation to 6-year postpartum. Follow-up included dyads anthropometrics, body composition, blood pressure, and child left ventricular function with comprehensive echocardiography (conventional and strain imaging).

RESULTS

Offspring left ventricular diastolic and systolic function was not associated with gestational glucose concentrations, GDM, or pregravida obesity. Child body fat percentage correlated with maternal pre-pregnancy BMI in the setting of maternal obesity (r = 0.23, P = 0.009). After adjusting for child lean body mass, age, sex, systolic BP, resting HR, maternal lean body mass, pre-gestational BMI, and GDM status, child left atrial volume increased by 0.3 ml (95% CI 0.1, 0.5) for each 1% increase in child body fat percentage.

CONCLUSIONS

No evidence of foetal cardiac programming related to GDM or maternal pre-pregnancy obesity was observed in early childhood. Maternal pre-pregnancy obesity is associated with early weight gain. Child adiposity in early childhood is independently associated with increased left atrial volume, but its implications for long-term left ventricle diastolic function and cardiovascular health remain unknown.

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.

Transgenerational effects of maternal obesity and gestational diabetes on offspring body composition and left ventricle mass: the Finnish Gestational Diabetes Prevention Study (RADIEL) 6-year follow-up

AIM

To investigate the influence of maternal adiposity and gestational diabetes on offspring body composition and left ventricle mass in early childhood.

METHODS

The observational follow-up study included 201 mother-child pairs, a sub-cohort from the Finnish Gestational Diabetes Prevention Study, who were recruited 6.1 ± 0.5 (mean ± SD) years postpartum, aiming for an equal number of mothers with and without gestational diabetes.

RESULTS

Maternal pre-pregnancy BMI (mean ± SD; 30.5 ± 5.6 kg/m² ) was associated with child body fat percentage [0.26 (95% CI; 0.08, 0.44)% increase in child body fat per 1 kg/m² increase in pre-pregnancy BMI of mothers with obesity] and was reflected in child BMI Z-score (mean ± SD; 0.45 ± 0.93). Left ventricle mass, left ventricle mass index and left ventricle mass Z-score were not associated with gestational diabetes, pre-pregnancy BMI or child body fat percentage. After adjusting for child sex, body fat percentage, systolic blood pressure, pre-pregnancy BMI and maternal lean body mass, left ventricle mass increased by 3.08 (95% CI; 2.25, 3.91) g for each 1 kg in child lean body mass.

CONCLUSIONS

Left ventricle mass at 6 years of age is determined predominantly by lean body mass. Maternal pre-gestational adiposity is reflected in child, but no direct association between left ventricle mass and child adiposity or evidence of left ventricle mass foetal programming related to gestational diabetes and maternal adiposity was observed in early childhood.

Effects of maternal lifestyle interventions on child neurobehavioral development: Follow-up of randomized controlled trials

Obesity is a major public health problem. Children of women who were obese before or during pregnancy are at increased risk for neurobehavioral developmental problems. Whether a maternal lifestyle intervention conducted before and during pregnancy in obese women affects child neurobehavioral development is unknown. This study reports on the follow‐up of a subsample of two randomized controlled trials, the Finnish RADIEL (n = 216) and Dutch LIFEstyle (n = 305) trial. Women with a pre‐pregnancy BMI ≥29 kg/m² wishing to conceive or who were already pregnant (<20 weeks) were allocated to a lifestyle intervention or to care as usual. Child neurodevelopment was measured with the Ages and Stages Questionnaire and child behavioral problems were measured with the Childhood Behavior Checklist (RADIEL) or the Strengths and Difficulties Questionnaire (LIFEstyle) at age 3‐6 years. We used linear and binary logistic regression analyses to assess the effects of the lifestyle interventions on children's neurobehavioral developmental scores. Follow‐up data was available from 161(38%) RADIEL and 96(32%) LIFEstyle children. Child neurodevelopmental scores did not differ significantly between children in the intervention and the control group (RADIEL:median = 275 vs. 280; LIFEstyle:median = 270 vs 267). Child behavioral problem scores did not differ significantly between children in the intervention and the control group (RADIEL:median = 22 vs. 21; LIFEstyle:median = 8 vs. 8). We did not observe considerable effects of the lifestyle interventions before or during pregnancy in obese women on child neurobehavioral development. With our sample sizes, we were not able to detect subtle differences in neurobehavioral development however.

Long-term effects of a preconception lifestyle intervention on cardiometabolic health of overweight and obese women

Background

The global prevalence of obesity in women keeps increasing. The preconception period may be a window of opportunity to improve lifestyle, reduce obesity and improve cardiometabolic health. This study assessed the effect of a preconception lifestyle intervention on long-term cardiometabolic health in two randomized controlled trials (RCTs).

Methods

Participants of the LIFEstyle and RADIEL preconception lifestyle intervention studies with a baseline body mass index (BMI) ≥29 kg/m² were eligible for this follow-up study. Both studies randomized between a lifestyle intervention targeting physical activity, diet and behaviour modification or usual care. We assessed cardiometabolic health 6 years after randomization.

Results

In the LIFEstyle study (n = 111) and RADIEL study (n = 39), no statistically significant differences between the intervention and control groups were found for body composition, blood pressure, arterial stiffness, fasting glucose, homeostasis model assessment of insulin resistance, HbA1c, lipids and high sensitive C-reactive protein levels 6 years after randomization. Participants of the LIFEstyle study who successfully lost ≥5% bodyweight or reached a BMI <29 kg/m² during the intervention (n = 22, [44%]) had lower weight (−8.1 kg; 99% CI [−16.6 to −0.9]), BMI (−3.3 kg/m²; [−6.5 to −0.8]), waist circumference (−8.2 cm; [−15.3 to −1.3]), fasting glucose (−0.5 mmol/L; [−1.1 to −0.0]), HbA1c (−4.1 mmol/mol; [−9.1 to −0.8]), and higher HDL-C (0.3 mmol/L; [0.1–0.5]) compared with controls.

Conclusion

We found no evidence of improved cardiometabolic health 6 years after a preconception lifestyle intervention among overweight and obese women in two RCTs. Women who successfully lost weight during the intervention had better cardiometabolic health 6 years later, emphasizing the potential of successful preconception lifestyle improvement.

Maternal obesity and gestational diabetes: Impact on arterial wall layer thickness and stiffness in early childhood - RADIEL study six-year follow-up

BACKGROUND AND AIMS

Gestational diabetes (GDM) and maternal obesity are linked to weight gain in childhood and an increased risk of cardiovascular disease later in life. We assessed the effects of GDM and maternal obesity on arterial function and morphology in relation to body anthropometrics and composition in early childhood.

METHODS

We assessed body size and composition, blood pressure (BP), arterial morphology and stiffness in 201 pairs of obese mothers (pre-pregnancy BMI 30.7 ± 5.6 kg/m², 96 with GDM) and their children at 6.1 years (SD 0.5).

RESULTS

Child BMI (z-score 0.45 ± 0.92; p < 0.001) and common carotid intima-media thickness (IMT, z-score 0.15 ± 0.75, p = 0.003) were increased compared with a healthy Finnish reference population. No associations with maternal GDM was found. Carotid IMT and pulse wave velocity were unrelated to child sex, anthropometrics, body composition, BP, as well as maternal anthropometrics and body composition. Carotid stiffness was independently predicted by second trimester fasting glucose. Child lean body mass was the strongest independent predictor for radial (RA), and brachial artery (BA) lumen diameter (LD) and BA IMT (LD: RA: r² = 0.068, p < 0.001; BA: r² = 0.108, p < 0.001; IMT: BA: r² = 0.161, p < 0.001) and carotid LD (r² = 0.066, p < 0.001).

CONCLUSIONS

Children of obese mothers have increased BMI, blood pressure and carotid IMT suggesting a transgenerational effect of maternal obesity and clustering of cardiovascular risk factors in the population. Arterial dimensions were mainly predicted by child LBM, and not associated with maternal or child adiposity, or GDM. There was a weak association with maternal gestational fasting glucose and increased carotid artery stiffness.

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.

Effect of gestational diabetes mellitus on newborn cholesterol metabolism

BACKGROUND AND AIMS

Impaired glucose metabolism during pregnancy may associate with changes in fetal cholesterol metabolism. We investigated if gestational diabetes mellitus (GDM) affects newborn cholesterol metabolism as determined by cord blood squalene and non-cholesterol sterols. Furthermore, we examined potential correlations between cord blood and maternal serum non-cholesterol sterols.

METHODS

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 taken in the third trimester of pregnancy, and cord blood samples collected from their newborns at birth. Squalene and non-cholesterol sterols were analyzed from serum and cord blood by gas liquid chromatography. All women with GDM were in good glycaemic control.

RESULTS

The ratios of squalene and non-cholesterol sterols to cholesterol (100 × μmol/mmol of cholesterol) in cord blood did not differ between the infants born to mothers with GDM (n = 15) or mothers with normal glucose tolerance (n = 13). The ratios of sitosterol and campesterol to cholesterol in the cord blood correlated with the corresponding maternal serum ratios (r = 0.70, p < 0.0001) in both groups.

CONCLUSIONS

In obese women under good glycaemic control, GDM did not affect newborn cholesterol metabolism. Cord blood sitosterol and campesterol ratios to cholesterol correlated with the corresponding maternal serum ratios thus potentially reflecting maternal-fetal cholesterol transport.

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.

Gut microbiome in gestational diabetes: a cross-sectional study of mothers and offspring 5 years postpartum

INTRODUCTION

An altered gut microbiome composition is shown to be associated with various diseases and health outcomes. We compare the gut microbiota of women who developed gestational diabetes mellitus (GDM) with that of those who did not, and the gut microbiota of their offspring, to determine any differences in the composition and diversity of their gut microbiota, which may be correlated with their GDM state.

MATERIAL AND METHODS

All women were at high risk for GDM and participated in the Finnish Gestational Diabetes Prevention Study (RADIEL). Stool samples were obtained, 5 years postpartum, from 60 GDM-positive women, 68 non-GDM control women, and their children (n = 109), 237 individuals in total. 16S ribosomal RNA gene sequencing was employed to determine the composition of bacterial communities present. Statistical correlations were inferred between clinical variables and microbiota, while taking into account potential confounders.

RESULTS

In mothers, no significant differences were observed in microbiota composition between the two groups. Genus Anaerotruncus was increased in children of women with GDM (p < 0.001). Beta-diversity measures showed that a mother and her child have a more similar microbiome composition when compared with unrelated children, other mothers, or the children compared with each other (p < 0.001).

CONCLUSIONS

These results suggest that there may be no discernible microbiome basis to GDM susceptibility in high-risk women, whereas microbiome differences between the offspring could be of greater biological significance. The heterogeneous nature of the disease could be obscuring potential differences between women. A longer time-series study, with carefully defined subject subgroups, may be an appropriate course of future investigation into GDM and the microbiome.

"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.

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.

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.