Impact of breastfeeding on maternal metabolism: implications for women with gestational diabetes

Lactating compared with nonlactating women display more favorable metabolic parameters, including less atherogenic blood lipids, lower fasting and postprandial blood glucose as well as insulin, and greater insulin sensitivity in the first 4 months postpartum. However, direct evidence demonstrating that these metabolic changes persist from delivery to postweaning is much less available. Studies have reported that longer lactation duration may reduce long-term risk of cardiometabolic disease, including type 2 diabetes, but findings from most studies are limited by self-report of disease outcomes, absence of longitudinal biochemical data, or no assessment of maternal lifestyle behaviors. Studies of women with a history gestational diabetes mellitus (GDM) also reported associations between lactation duration and lower the incidence of type 2 diabetes and the metabolic syndrome. The mechanisms are not understood, but hormonal regulation of pancreatic β-cell proliferation and function or other metabolic pathways may mediate the lactation association with cardiometabolic disease in women.

Impaired decline in renal threshold for glucose during pregnancy - a possible novel mechanism for gestational diabetes mellitus

BACKGROUND

The renal threshold for glucose (RT(G)) is determined by the nephron's reabsorptive capacity. Glucose is reabsorbed through sodium-coupled glucose cotransporters in the proximal tubules. During pregnancy, renal glucose reabsorptive capacity decreases, possibly, due to reduced glucose transporter expression. Our hypothesis is that inadequate decrease in RT(G) during pregnancy will make women more prone to develop gestational diabetes mellitus (GDM).

METHODS

Pregnant women (n = 40) who were referred to our center for oral glucose tolerance test (OGTT) were included in the analysis. Plasma glucose levels and urinary glucose excretion were measured for 4 h after 100 g oral glucose load. These data were used to calculate RT(G) . The subjects were divided into two cohorts, GDM and non-GDM, according to the OGTT results. Mean RT(G) was compared between the two groups.

RESULTS

Fifteen (37.5%) of the women were diagnosed with GDM. Seventeen participants had only trace amounts of urinary glucose excretion, and no value of RT(G) could be determined; RT(G) was determined in the other 23 subjects. Among these 23 women, 13 were diagnosed as GDM, and 10 had normal OGTT. RT(G) was lower in the non-GDM women (146 ± 14 mg/dL) than in the GDM women (182 ± 18 mg/dL), p < 0.001.

CONCLUSIONS

Gestational diabetes mellitus is associated with higher RT(G) during pregnancy compared with non-GDM. These results support our hypothesis that inadequate decrease of the RT(G) may have a pathophysiological role in the development of GDM.

Increased risk for overweight among Swedish children born to mothers with gestational diabetes mellitus

OBJECTIVE

Investigate the effects of maternal gestational diabetes mellitus (GDM) on height, weight, and body mass index (BMI) in offspring compared both to their siblings and to age-specific BMI reference values in Sweden. Their parents present BMI was also investigated.

METHODS

The growth of 232 offspring to 110 women with at least one pregnancy with GDM, were studied up to 12 yr of age. Height and weight of children were collected from Health Care Centres and compared to age-specific reference values in Sweden. Self-reported height and weight of the parents were collected at follow-up.

RESULTS

For boys, weight was higher at birth and at 8-10 yr of age, giving a higher BMI at 7-10 yr of age. Girls had an accelerated height growth at all ages, combined with an increased weight of varying degree resulting in higher BMI at birth and at 4-12 yr of age. A similar pattern was observed in siblings born after a normal pregnancy. Median BMI of mothers at follow-up was 25.4 (18.3-59.5 n = 105) and 26.5 (18.6-38.1 n = 90) for fathers.

CONCLUSIONS

Children born to mothers with prior GDM have a higher risk of overweight and obesity later in life. This is most likely due to life style habits rather than intrauterine factors, as the same BMI pattern was found in siblings born after a normal pregnancy. However, the design of the study could not rule out the role of genetic factors. Priority should be given to early life style intervention in these families.

The relationship and potential mechanistic pathways between sleep disturbances and maternal hyperglycemia

This paper reviews recent work investigating the influence of sleep disturbances on maternal hyperglycemia, particularly gestational diabetes mellitus (GDM). The incidence and prevalence of hyperglycemia are increasing worldwide, which is cause for concern because GDM and even mild hyperglycemia are associated with adverse pregnancy outcomes. A better understanding of sleep-related risk factors for maternal hyperglycemia is an important health matter. Evidence demonstrates associations between sleep disturbances, especially sleep-disordered breathing, and hyperglycemia, but causal effects and the underlying mechanisms linking these conditions have not been fully elucidated. Subjective sleep assessments show associations between sleep disturbances and maternal hyperglycemia. There are, however, few studies using objective measures to support these findings. Large prospective studies are required to examine causal relationships between sleep disturbances and maternal hyperglycemia. There is also a need for smaller mechanistic studies to understand the pathophysiology. Furthermore, interventional studies are required to address whether improvement of sleep parameters can prevent/decrease the risk of developing maternal hyperglycemia. Taken together, the data suggests that sleep disturbances during pregnancy are important to identify and manage in order to minimize maternal hyperglycemia and GDM, and improve maternal and fetal well-being.

Effect of pre-existing maternal obesity, gestational diabetes and adipokines on the expression of genes involved in lipid metabolism in adipose tissue

OBJECTIVE

To determine the effect of maternal obesity, gestational diabetes mellitus (GDM) and adipokines on the expression of genes involved in fatty acid uptake, transport, synthesis and metabolism.

MATERIALS/METHODS

Human subcutaneous and omental adipose tissues were obtained from lean, overweight and obese normal glucose tolerant (NGT) women and women with GDM. Quantitative RT-PCR (qRT-PCR) was performed to determine the level of expression. Adipose tissue explants were performed to determine the effect of the adipokines TNFα, IL-1β and leptin on adipose tissue gene expression.

RESULTS

Pre-existing maternal obesity and GDM are associated with decreased expression in genes involved in fatty acid uptake and intracellular transport (LPL, FATP2, FATP6, FABPpm and ASCL1), triacylglyceride (TAG) biosynthesis (MGAT1,7 MGAT2 and DGAT1), lipogenesis (FASN) and lipolysis (PNPLA2, HSL and MGLL). Decreased gene expression was also observed for the transcription factors involved in lipid metabolism (LXRα, PPARα, PPARδ, PPARγ, RXRα and SREBP1c). On the other hand, the gene expression of the adipokines TNFα, IL-1β and or leptin was increased in adipose tissue from obese and GDM women. Functional in vitro studies revealed that these adipokines decreased the gene expression of LPL, FATP2, FATP6, ASCL1, PNPLA2, PPARδ, PPARγ and RXRα.

CONCLUSIONS

Pregnancies complicated by pre-existing maternal obesity and GDM are associated with abnormal adipose tissue lipid metabolism, which may play a role in the pathogenesis of these diseases.

Reasons for participation and non-participation in a diabetes prevention trial among women with prior gestational diabetes mellitus (GDM)

BACKGROUND

Gestational diabetes mellitus (GDM) is a risk factor for the development of type 2 diabetes. Lifestyle intervention can prevent progression to type 2 diabetes in high risk populations. We designed a randomised controlled trial (RCT) to evaluate the effectiveness of an established lifestyle intervention compared to standard care for delaying diabetes onset in European women with recent GDM. Recruitment into the RCT was more challenging than anticipated with only 89 of 410 (22%) women agreeing to participate. This paper identifies factors that could enhance participation of the target population in future interventions.

METHODS

We hypothesised that women who agreed to participate would have higher diabetes risk profiles than those who declined, and secondly that it would be possible to predict participation on the bases of those risk factors. To test our hypothesis, we identified the subset of women for whom we had comprehensive data on diabetes risks factors 3-5 years following GDM, reducing the sample to 43 participants and 73 decliners. We considered established diabetes risk factors: smoking, daily fruit and vegetable intake, participation in exercise, family history of diabetes, glucose values and BMI scores on post-partum re-screens, use of insulin during pregnancy, and age at delivery. We also analysed narrative data from 156 decliners to further understand barriers to and facilitators of participation.

RESULTS

Two factors differentiated participants and decliners: age at delivery (with women older than 34 years being more likely to participate) and insulin use during pregnancy (with women requiring the use of insulin in pregnancy less likely to participate). Binary logistic regression confirmed that insulin use negatively affected the odds of participation. The most significant barriers to participation included the accessibility, affordability and practicality of the intervention.

CONCLUSIONS

Women with recent GDM face multiple barriers to lifestyle change. Intervention designers should consider: (i) the practicalities of participation for this population, (ii) research designs that capitalise on motivational differences between participants, (iii) alleviating concerns about long-term diabetes management. We hope this work will support future researchers in developing interventions that are more relevant, effective and successful in recruiting the desired population.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41202110.

Screening uptake rates and the clinical and cost effectiveness of screening for gestational diabetes mellitus in primary versus secondary care: study protocol for a randomised controlled trial

BACKGROUND

The risks associated with gestational diabetes mellitus (GDM) are well recognized, and there is increasing evidence to support treatment of the condition. However, clear guidance on the ideal approach to screening for GDM is lacking. Professional groups continue to debate whether selective screening (based on risk factors) or universal screening is the most appropriate approach. Additionally, there is ongoing debate about what levels of glucose abnormalities during pregnancy respond best to treatment and which maternal and neonatal outcomes benefit most from treatment. Furthermore, the implications of possible screening options on health care costs are not well established. In response to this uncertainty there have been repeated calls for well-designed, randomised trials to determine the efficacy of screening, diagnosis, and management plans for GDM. We describe a randomised controlled trial to investigate screening uptake rates and the clinical and cost effectiveness of screening in primary versus secondary care settings.

METHODS/DESIGN

This will be an unblinded, two-group, parallel randomised controlled trial (RCT). The target population includes 784 women presenting for their first antenatal visit at 12 to 18 weeks gestation at two hospitals in the west of Ireland: Galway University Hospital and Mayo General Hospital. Participants will be offered universal screening for GDM at 24 to 28 weeks gestation in either primary care (n=392) or secondary care (n=392) locations. The primary outcome variable is the uptake rate of screening. Secondary outcomes include indicators of clinical effectiveness of screening at each screening site (primary and secondary) including gestational week at time of screening, time to access antenatal diabetes services for women diagnosed with GDM, and pregnancy and neonatal outcomes for women with GDM. In addition, parallel economic and qualitative evaluations will be conducted. The trial will cover the period from the woman's first hospital antenatal visit at 12 to 18 weeks gestation, until the completion of the pregnancy.

TRIAL REGISTRATION

Current Controlled Trials: ISRCTN02232125.

Gestational Diabetes Independently Increases Birth Length and Augments the Effects of Maternal BMI on Birth Weight: A Retrospective Cohort Study

OBJECTIVE

To investigate the effect of the interaction between gestational diabetes mellitus (GDM) and maternal body mass index (BMI) on the individual neonatal growth parameters.

DESIGN

Retrospective cohort study.

SETTING

A tertiary maternity service in Sydney, Australia, between 2005 and 2009.

POPULATION

A cohort of 8859 women.

METHODS

Generalized linear models.

MAIN OUTCOME MEASURES

Neonatal growth parameters, represented by z-scores for infant birth weight (BW), birth length (BL), and head circumference (HC) in GDM and non-GDM groups.

RESULTS

Only GDM alone had an independent and positive effect on BL (p = 0.02) but not on BW or HC. In addition, in pregnancies complicated with GDM, the association between maternal weight and BW was significantly stronger (p < 0.001). In combination, GDM and maternal BMI significantly affected z-score differences between BW and BL (p < 0.001), in that underweight mothers had babies that were lighter relative to their length and inversely obese mothers had babies that were heavier relative to their length.

CONCLUSION

GDM independently influences BL and increases the association between maternal BMI and BW. In accordance with the hypothesis of the fetal origins of health and disease, the pronounced effects of GDM on fetal growth patterns demonstrated in this study are likely to influence long-term health outcomes in children.

Vitamin D and gestational diabetes mellitus

Gestational diabetes mellitus (GDM) complicates 7 %-14 % of pregnancies in the United States. Vitamin D deficiency also is common in pregnancy. Emerging evidence suggests that Vitamin D administration can improve insulin sensitivity and glucose tolerance, but whether vitamin D supplementation can prevent GDM is unknown. Observational studies provide conflicting evidence as to whether low serum 25-hydroxyvitmain D (25(OH)D) levels are associated with GDM. Two recent systematic reviews concluded that vitamin D deficiency is associated with a higher risk of GDM. However, these reviews are limited by the observational and diverse nature of the included studies. Of greatest concern is the inability to understand how important confounding variables such as race/ethnicity and adiposity might affect the association. Randomized controlled trial data remain limited but are critical to understanding whether supplementation with vitamin D beyond what is contained in routine prenatal vitamins will prevent GDM or improve glucose tolerance for women with GDM.

Prevalence of gestational diabetes mellitus and its correlation with blood pressure in Manipuri women

Objective:

The aim and objective was to study the prevalence of gestational diabetes mellitus (GDM) by using National Diabetes Data Group (NDDG) and American Diabetes Association (ADA) (2004) criteria and the correlation of GDM with gestational blood pressure (BP) and maternal age.

Study Design:

This was a cross-sectional study in which 300 pregnant women in 24-28 weeks of pregnancy who screened positive with 1-h glucose load ≥ 140 mg/dL underwent a diagnostic 3-h oral glucose tolerance test (OGTT). BP was obtained by review of the medical records.

Results:

Thirty-seven (12.33%) women were screened positive with 50 g glucose challenge test (GCT) (≥140 mg%) out of the 300 participants. With 100 g 3-h OGTT among these 37 women, none of them fulfilled the NDDG diagnostic criteria for GDM. However, on using the ADA (2004) criteria, three (8.1%) women were diagnosed to have GDM. All three of them had systolic BP between 120 and 139 mmHg; two of them had diastolic BP between 80 and 89 mmHg. Among 37 subjects with GCT > 140 mg%, majority were older than 26 years.

Conclusion:

Using the ADA (2004) guideline, 1% of the total study population had GDM. The BP of these patients fell within the prehypertensive range, thus suggesting an association between GDM and BP.

Estradiol Binds to Insulin and Insulin Receptor Decreasing Insulin Binding in vitro

RATIONALE

Insulin (INS) resistance associated with hyperestrogenemias occurs in gestational diabetes mellitus, polycystic ovary syndrome, ovarian hyperstimulation syndrome, estrogen therapies, metabolic syndrome, and obesity. The mechanism by which INS and estrogen interact is unknown. We hypothesize that estrogen binds directly to INS and the insulin receptor (IR) producing INS resistance.

OBJECTIVES

To determine the binding constants of steroid hormones to INS, the IR, and INS-like peptides derived from the IR; and to investigate the effect of estrogens on the binding of INS to its receptor.

METHODS

Ultraviolet spectroscopy, capillary electrophoresis, and NMR demonstrated estrogen binding to INS and its receptor. Horse-radish peroxidase-linked INS was used in an ELISA-like procedure to measure the effect of estradiol on binding of INS to its receptor.

MEASUREMENTS

Binding constants for estrogens to INS and the IR were determined by concentration-dependent spectral shifts. The effect of estradiol on INS binding to its receptor was determined by shifts in the INS binding curve.

MAIN RESULTS

Estradiol bound to INS with a K d of 12 × 10(-9) M and to the IR with a K d of 24 × 10(-9) M, while other hormones had significantly less affinity. Twenty-two nanomolars of estradiol shifted the binding curve of INS to its receptor 0.8 log units to the right.

CONCLUSION

Estradiol concentrations in hyperestrogenemic syndromes may interfere with INS binding to its receptor producing significant INS resistance.

Association between neonatal hypoglycaemia and prediabetes in postpartum women with a history of gestational diabetes

AIMS AND OBJECTIVES

To determine the association between hypoglycaemia among neonates born to mothers with gestational diabetes mellitus and their postpartum prediabetes.

BACKGROUND

Infants born to mothers with diabetes who experienced hyperglycaemia are more likely to develop hypoglycaemia.

DESIGN

A prospective-descriptive research was conducted in three tertiary hospitals in southern Thailand.

METHODS

One hundred and fifty matched pairs of mothers and their newborns were included in the study. Data were analysed using descriptive statistic, odds ratio, Spearman's rho correlation and binary logistic regression.

RESULTS

The incidence of neonatal hypoglycaemia was 42·37% and odds ratio was 0·30. The findings showed the significant association between neonatal hypoglycaemia and postpartum blood sugar levels of women with a history of gestational diabetes mellitus.

CONCLUSIONS

Neonatal hypoglycaemia was associated with maternal hyperglycaemia and prediabetes.

RELEVANCE TO CLINICAL PRACTICE

Neonatal hypoglycaemia might be used to predict prediabetes of postpartum women with a history of gestational diabetes mellitus.

Serum levels of irisin in gestational diabetes mellitus during pregnancy and after delivery

OBJECTIVE

Irisin has recently been introduced as a novel an exercise-inducible myokine which improves glucose metabolism in mice. However, regulation of circulating irisin in gestational diabetes mellitus (GDM) and in the peripartal period has not been assessed so far.

METHODS

Circulating irisin was quantified in 74 GDM patients and in 74 healthy, pregnant, gestational age-matched controls. In a subset of these patients (44 GDM, 41 controls), postpartum follow-up data were also available. In a second study population of 40 healthy women with singleton pregnancies undergoing elective Cesarean section, irisin was assessed in maternal serum before and within 24h after delivery, as well as in umbilical cord blood and in placental tissue.

RESULTS

In the first study population, median [interquartile range] irisin levels were significantly higher in GDM patients as compared to controls after delivery (previous GDM: 446.3 [146.9]μg/l; controls: 378.0 [111.4]μg/l) but not during pregnancy (GDM: 482.1 [132.1]μg/l; controls: 466.6 [178.0]μg/l). Interestingly, fasting insulin (FI) was independently and positively associated with serum irisin in multivariate analysis during pregnancy. In agreement with these findings, relative changes (ratio) of FI independently and positively predicted relative changes of irisin (ratio) in the second study population.

CONCLUSIONS

The myokine irisin is independently associated with FI in pregnancy. The physiological significance of these findings needs to be assessed in future experiments.

Effect of oxidative stress on heme oxygenase-1 expression in patients with gestational diabetes mellitus

The anti-oxidative stress effect of heme oxygenase-1 (HO-1) expression is being increasingly studied. However, few studies regarding HO-1 have been conducted in patients with gestational diabetes mellitus (GDM). In the present study, HO-1 expression was compared in peripheral blood mononuclear cells at 24-28 weeks of pregnancy in patients with GDM and healthy females, to investigate the correlation between HO-1 and oxidative stress by calculation of MDA content in the peripheral blood serum (thiobarbituric acid method), tested ROS (flow cytometry method), HO-1mRNA (RT-PCR method), and HO-1 protein (western blotting method) of Mononuclear cells. The results show that the levels of serum malonaldehyde (MDA), reactive oxygen species (ROS), HO-1 mRNA and HO-1 protein expression in peripheral blood mononuclear cells were higher in the GDM group than in the control group. Correlation analysis showed that the expression levels of HO-1 protein were positively correlated with the HO-1 mRNA expression levels (r=0.680; P=0.000), and the levels of ROS (r=0.572; P=0.000) and MDA (r=0.614; P=0.000). HO-1 mRNA expression levels were found to positively correlate with the levels of MDA (r=0.451; P=0.010) and fasting plasma glucose (FPG; r=0.337; P=0.039). Partial correlation analysis demonstrated that, after removing the effects of body mass index, FPG and 2-h plasma glucose, HO-1 protein expression levels were positively correlated with the levels of HO-1 mRNA expression (r=0.611; P=0.005), ROS (r=0.526; P=0.021) and MDA (r=0.519; P=0.015). These findings indicate that pregnant females with GDM may be protected against oxidative injury due to the induction of adaptive and compensatory expression of HO-1 to guard against oxidative stress induced by high glucose levels.

Vitamin D deficiency in gestational diabetes mellitus and the role of the placenta

OBJECTIVE

The aim of this study was to evaluate the relationships between maternal vitamin D levels and gestational diabetes mellitus (GDM) and differences in the placental production of vitamin D receptor (VDR), CYP24A, and CYP27B1.

STUDY DESIGN

Forty normal pregnant women and 20 women with GDM were included in this study. Serum levels of 25-hydroxyvitamin D (25[OH]D) were measured with enzyme-linked immunosorbent assay. The expression and production of VDR, CYP27B1, and CYP24A1 in the placenta were evaluated with real time-polymerase chain reaction and Western blot, respectively.

RESULTS

We found that 27.5% of normal pregnant women and 85% of women with GDM had vitamin D deficiency, with serum 25(OH)D levels <20 ng/mL. Serum levels of 25(OH)D were lower in women with GDM than normal pregnant women (P < .01). The production of CYP24A1 protein and messenger RNA expression was significantly higher in placental tissue from patients with GDM than in those from normal pregnancies; however, the production of CYP27B1 and VDR protein and messenger RNA expression were not different between 2 the groups.

CONCLUSION

In this study, vitamin D deficiency was associated with GDM. Given that 25(OH)D is hydroxylated by CYP27B1 to the bioactive 1,25(OH)2D form, and CYP24A1 catabolizes both 25(OH)D and 1,25(OH)2D to the inactive metabolites, respectively, our data indicate that the elevated activity of CYP24A1 in the placenta may play a key role in the development of vitamin D deficiency in GDM.

Longitudinal changes in insulin sensitivity and beta cell function between women with and without a history of gestational diabetes mellitus

AIMS/HYPOTHESIS

The aim of the study was to compare longitudinal changes in insulin sensitivity (SI) and beta cell function between women with and without a history of gestational diabetes mellitus (GDM).

METHODS

The prospective follow-up cohort included 235 parous non-diabetic Mexican-American women, 93 with and 142 without a history of GDM. The participants underwent dual-energy x-ray absorptiometry, OGTTs and IVGTTs at baseline and at a median of 4.1 years follow-up. The baseline values and rates of change of metabolic measures were compared between groups.

RESULTS

At baseline, women with prior GDM (mean age 36.3 years) had similar values of SI but higher percentages of body fat and trunk fat (p ≤ 0.02), a lower acute insulin response and poorer beta cell compensation (disposition index [DI]) (p < 0.0001) than women without GDM (mean age 37.9 years). During the follow-up, women with GDM had a faster decline in SI (p = 0.02) and DI (p = 0.02) than their counterparts without GDM, with no significant differences in changes of weight or fat (p > 0.50). Adjustment for baseline age, adiposity, calorie intake, physical activity, age at first pregnancy, additional pregnancies and changes in adiposity during follow-up increased the between-group differences in the rates of change of SI and DI (p ≤ 0.003).

CONCLUSIONS/INTERPRETATION

Mexican-American women with recent GDM had a faster deterioration in insulin sensitivity and beta cell compensation than their parous counterparts without GDM. The differences were not explained by differences in adiposity, suggesting more deleterious effects of existing fat and/or reduced beta cell robustness in women with GDM.

Advancements and challenges in generating accurate animal models of gestational diabetes mellitus

The maintenance of glucose homeostasis during pregnancy is critical to the health and well-being of both the mother and the developing fetus. Strikingly, approximately 7% of human pregnancies are characterized by insufficient insulin production or signaling, resulting in gestational diabetes mellitus (GDM). In addition to the acute health concerns of hyperglycemia, women diagnosed with GDM during pregnancy have an increased incidence of complications during pregnancy as well as an increased risk of developing type 2 diabetes (T2D) later in life. Furthermore, children born to mothers diagnosed with GDM have increased incidence of perinatal complications, including hypoglycemia, respiratory distress syndrome, and macrosomia, as well as an increased risk of being obese or developing T2D as adults. No single environmental or genetic factor is solely responsible for the disease; instead, a variety of risk factors, including weight, ethnicity, genetics, and family history, contribute to the likelihood of developing GDM, making the generation of animal models that fully recapitulate the disease difficult. Here, we discuss and critique the various animal models that have been generated to better understand the etiology of diabetes during pregnancy and its physiological impacts on both the mother and the fetus. Strategies utilized are diverse in nature and include the use of surgical manipulation, pharmacological treatment, nutritional manipulation, and genetic approaches in a variety of animal models. Continued development of animal models of GDM is essential for understanding the consequences of this disease as well as providing insights into potential treatments and preventative measures.

Gestational diabetes mellitus, programing and epigenetics

Gestational diabetes mellitus (GDM) is a common medical complication in pregnancy. Offspring exposed to maternal hyperglycemia have a higher birth weight and are prone to develop metabolic disease in adult life. The intrauterine environmental or nutritional status seems to be involved in the fetal programing. The concept of "Developmental Origins of Health and Disease" (DOHaD) has been widely accepted and it brings new insights into the molecular pathogenesis of human diseases. The underlying mechanism is still under discussion and epigenetic mechanisms may provide an explanation for the phenomenon. The aim of this review is to illustrate the role of epigenetic modifications in the development of insulin resistance in metabolic diseases induced by adverse intrauterine exposures. Changes in epigenetic mechanism may be an early event in pathogenesis and progression of the metabolic disease in humans. Studies on epigenetic modifications contribute to our understanding of long-term effects of in utero exposure and shed light on the disease prevention and treatment by modulating epigenetic changes.

Doppler flow parameters in orbital arteries in gestational diabetes mellitus patients

OBJECTIVE

To evaluate the blood flow in orbital arteries in patients with gestational diabetes mellitus (GDM).

MATERIAL

We have examined 65 GDM patients and 38 healthy pregnant women at 28-32 weeks. Doppler parameters were assessed in ophthalmic, central retinal and short posterior ciliary arteries.

RESULTS

In ophthalmic arteries V2 was significantly higher and RI lower in GDM. In the subgroup treated with insulin V1 and V2 in ciliary artery and V2 in central retinal artery were significantly lower and PI in ciliary artery was higher when compared to subgroup on diet.

CONCLUSION

Doppler examination can be useful in detection of pre-clinical ophthalmological changes in GDM patients.

Expression of toll-like receptor 4 in maternal monocytes of patients with gestational diabetes mellitus

Toll-like receptors (TLRs) are pattern recognition receptors and play an important role in innate immune responses and the occurrence of inflammatory disease. TLR4 is a member of the TLR family and its activation is capable of inducing inflammatory responses, reflecting a relationship between the innate and adaptive immune systems. However, whether TLR4 is expressed in patients with gestational diabetes mellitus (GDM) has not been elucidated. The aim of the present study was to investigate whether TLR4 is expressed in maternal peripheral blood monocytes of patients with GDM. A case-control study, using standard quantitative polymerase chain reaction and western blotting, was performed to assess the TLR4 expression in 30 females with GDM and 32 healthy pregnant females at similar gestational ages. Serum tumor necrosis factor (TNF)-α levels were assessed using ELISA in all the females. The TLR4 expression levels in the maternal peripheral blood monocytes and the serum TNF-α levels were increased in females with GDM compared with healthy pregnant females (P<0.05). Additionally, there was a positive correlation between the TLR4 expression level in peripheral blood monocytes and serum TNF-α levels in all the females. These results indicate that TLR4-mediated release of inflammatory cytokines may represent one factor leading to increased glucose levels in patients with GDM. In addition, TLR4 may be involved in the pathogenesis of GDM.

Comparative study between different biomarkers for early prediction of gestational diabetes mellitus

OBJECTIVE

To study various biomarkers in prediction of gestational diabetes mellitus (GDM).

PATIENTS AND METHODS

Prospective observational study included 400 pregnant women. Maternal serum sex hormone binding globulin (SHBG), high-sensitive C-reactive protein (hs-CRP), uric acid, creatinine and albumin were measured before 15 weeks of gestation. Patients were followed-up for development of GDM.

RESULTS

A total of 269 women were eligible for analysis. GDM complicated 27 (10.03%) of pregnancies. Hs-CRP levels were significantly higher and SHBG levels were significantly lower among women who subsequently developed GDM compared with normoglycemics. Uric acid, albumin and creatinine levels were not significantly different between both groups. For prediction of GDM, hs-CRP at a cutoff value of 2.55 mg/l showed a sensitivity and a specificity of 89% and 55%, respectively. SHBG at a cutoff value of 211.5 nmol/l showed a sensitivity and a specificity of 85% and 37%, respectively. Low SHBG with high hs-CRP predicted GDM with a sensitivity and specificity of 74.07% and 75.62%, respectively with an overall accuracy of 75.46%.

CONCLUSION

Hs-CRP and SHBG are important early predictors of GDM. Adding SHBG to hs-CRP improves specificity and serves good overall accuracy. Uric acid, creatinine and albumin have no role in GDM prediction.

History of infertility and risk of gestational diabetes mellitus: a prospective analysis of 40,773 pregnancies

Studies of delayed conception and risk of gestational diabetes (GDM) are sparse, although common underlying mechanisms are plausible, including insulin resistance and inflammation. The association between a history of infertility and GDM was assessed prospectively among 40,773 eligible pregnancies in the US Nurses' Health Study II cohort (1989-2001). Biennial questionnaires provided updated information on infertility and several lifestyle and health-related characteristics. Multivariable log-binomial models with generalized estimating equations were used to compute risk ratios and 95% confidence intervals, adjusting for age, prepregnancy body mass index (weight (kg)/height (m)(2)), and additional potential confounders. GDM occurred among 1,405 (5.2%) women. A prepregnancy history of infertility was reported by 5,497 (20.5%) participants and was significantly associated with a 39% greater risk of GDM (risk ratio (RR) = 1.39, 95% confidence interval (CI): 1.24, 1.57; P < 0.001). Underlying reasons for infertility associated with GDM included ovulation disorders (RR = 1.52, 95% CI: 1.23, 1.87; P < 0.001) and tubal blockage (RR = 1.83, 95% CI: 1.20, 2.77; P = 0.005). The association of cervical mucus disorder with GDM was of borderline significance (RR = 1.70, 95% CI: 0.88, 3.30; P = 0.11). Endometriosis (RR = 1.27, 95% CI: 0.70, 2.31; P = 0.43) and male factor infertility (RR = 1.12, 95% CI: 0.78, 1.61; P = 0.55) were not associated with GDM risk. These novel findings suggest that infertility, particularly from ovulation disorders and tubal blockage, is associated with an increased GDM risk. Further research is needed to identify mechanisms or common underlying metabolic dysfunction explaining these observations.

Materno-fetal transfer of docosahexaenoic acid is impaired by gestational diabetes mellitus

Better knowledge on the disturbed mechanisms implicated in materno-fetal long-chain polyunsaturated fatty acid (LC-PUFA) transfer in pregnancies with gestational diabetes mellitus (GDM) may have potentially high implications for later on in effective LC-PUFA supplementation. We studied in vivo placental transfer of fatty acids (FA) using stable isotope tracers administrated to 11 control and 9 GDM pregnant women (6 treated with insulin). Subjects received orally [(13)C]palmitic, [(13)C]oleic and [(13)C]linoleic acids, and [(13)C]docosahexaenoic acid ((13)C-DHA) 12 h before elective caesarean section. Maternal blood samples were collected at -12, -3, -2, and -1 h, delivery, and +1 h. Placental tissue and venous cord blood were also collected. FA were quantified by gas chromatography (GC) and (13)C enrichments by GC-isotope ratio mass spectrometry. [(13)C]FA concentration was higher in total lipids of maternal plasma in GDM vs. controls, except for [(13)C]DHA. Moreover, [(13)C]DHA showed lower placenta/maternal plasma ratio in GDM vs. controls and significantly lower cord/maternal plasma ratio. For the other studied FA, ratios were not different between GDM and controls. Disturbed [(13)C]DHA placental uptake occurs in both GDM treated with diet or insulin, whereas the last ones also have lower [(13)C]DHA in venous cord. The tracer study pointed toward impaired placental DHA uptake as critical step, whereas the transfer of the rest of [(13)C]FA was less affected. GDM under insulin treatment could also have higher fetal fat storage, contributing to reduce [(13)C]DHA in venous cord. DHA transfer to the fetus was reduced in GDM pregnancies compared with controls, which might affect the programming of neurodevelopment in their neonates.

Lipoprotein(a) is not related to markers of insulin resistance in pregnancy

BACKGROUND

Dyslipidemia, a major risk factor for cardiovascular disease is a common finding in patients with type 2 diabetes and among women with gestational diabetes. Elevated levels of lipoprotein(a) [Lp(a)] are linked to increased risk of cardiovascular disease. However, its relationship with insulin resistance, type 2 diabetes and gestational diabetes is controversial and unproven. Here we aimed to clarify whether Lp(a) levels are associated with insulin sensitivity in pregnancy.

METHODS

Sixty-four women with gestational diabetes and 165 with normal glucose tolerance were enrolled in the study. Fasting Lp(a) serum levels were measured in all women at 24-28 weeks of gestation.

RESULTS

In pregnancy, there was no significant difference in serum Lp(a) concentrations between the two groups. Its level did not correlate with markers of insulin resistance (HOMA-IR), insulin sensitivity (HOMA-S%), pancreatic beta-cell function (HOMA-B%) and insulin sensitivity in dynamic conditions (OGIS). In addition, fasting glucose and insulin levels and those throughout an oral glucose tolerance test were independent of Lp(a) concentrations in our study group.

CONCLUSIONS

Lp(a) levels in pregnant women do not differ with respect to the presence or absence of gestational diabetes. Although influenced by some components of the lipid profile, such as triglycerides and HDL-C, insulin resistance in pregnancy is not affected by Lp(a).

PPAR activation as a regulator of lipid metabolism, nitric oxide production and lipid peroxidation in the placenta from type 2 diabetic patients

Peroxisome proliferator activated receptors (PPARs) are ligand activated transcription factors with crucial functions in lipid homeostasis, anti-inflammatory processes and placental development. Maternal diabetes induces a pro-inflammatory environment and alters placental development. We investigated whether PPARs regulate lipid metabolism and nitric oxide (NO) production in placental explants from healthy and type 2 diabetic (DM2) patients. We found decreased PPARα and PPARγ concentrations, no changes in PPARδ concentrations, and increased lipids, lipoperoxides and NO production in placentas from DM2 patients. PPARα agonists reduced placental concentrations of triglycerides and both PPARα and PPARδ agonists reduced concentrations of phospholipids, cholesteryl esters and cholesterol. PPARγ agonists increased lipid concentrations in placentas from DM2 patients and more markedly in placentas from healthy patients. Endogenous ligands for the three PPAR isotypes reduced NO production and lipoperoxidation in placentas from DM2 patients. We conclude that PPARs play a role in placental NO and lipid homeostasis and can regulate NO production, lipid concentrations and lipoperoxidation in placentas from DM2 patients.

Psychosocial management of diabetes in pregnancy

This consensus based national guideline addresses the need for psychological, psychiatric and social assessment, as well as management, in antenatal women with diabetes. It builds upon the earlier Indian guidelines on psychological management of diabetes, and should be considered as an addendum to the parent guideline.

Diagnostic effectiveness of 75 g oral glucose tolerance test for gestational diabetes in India based on the International Association of the Diabetes and Pregnancy Study Groups guidelines

BACKGROUND

To determine the diagnostic effectiveness of the fasting and one-hour plasma glucose levels for gestational diabetes (GDM) based on International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria.

METHODS

A Cross-sectional study that included 2348 pregnant women booked for antenatal care in 2011 at a tertiary care perinatal institute. Pregnant women underwent a 75 g oral glucose tolerance test (OGTT) between 24 and 28 weeks of gestation. Outcome measures include the incidence of GDM based on the IADPSG criteria and the diagnostic effectiveness of the recommended fasting and one-hour plasma glucose cut-off if used in isolation.

RESULTS

The incidence of GDM was 21.81% (n = 520, 95% CI: 20.15, 23.57) with the IADPSG criteria. A fasting plasma glucose cut-off 92 mg/dL, in isolation, correctly classified 87.16% of GDM, with a specificity of 96.08%, clinically significant positive likelihood ratio (14.08) and a post-test probability of 79.71%. The one-hour 75 g test, in isolation, correctly classified 85.74% of GDM, had specificity of 99.68% and clinically significant positive likelihood ratio (111.12) and post-test probability of 96.87%. The application of the World Health Organization criteria would misclassify 11.91% (95% CI: 10.66, 13.26) of GDM as normal.

CONCLUSIONS

Additional testing of plasma glucose levels can be avoided for 18.25% (n = 435, 95% CI: 16.73, 19.84) if the IADPSG diagnostic criteria for GDM are applied with exit on a positive fasting or one-hour test result.

The potential impact of new diagnostic criteria on the frequency of gestational diabetes mellitus in Sweden

The International Association of Diabetes and Pregnancy Study Groups (IADPSG) has suggested new diagnostic criteria for gestational diabetes mellitus. Many centers in Europe still use the World Health Organization (WHO) criteria. In southern Sweden we use the 2-h threshold of the European Association for the Study of Diabetes criteria based on universal screening with a 75-g oral glucose tolerance test. We have retrospectively scrutinized oral glucose tolerance tests in a subset of 174 women included in a previous study, diagnosed with gestational diabetes mellitus 1996-1999. A complete repeat oral glucose tolerance test was performed directly after diagnosis in 120 women. When applying the current Swedish criteria, and the IADPSG and the WHO criteria to the material, gestational diabetes mellitus was confirmed in 67% (80/120), 84% (101/120), and 80% (96/120), respectively. Hence, 26% (101/80) more women were identified by the IADPSG criteria and 20% (96/80) more women by the WHO criteria, compared with the criteria presently in use.

Evaluation of oral glucose tolerance test, β-cell function and adverse obstetric outcomes

This study was conducted in order to investigate the prevalence of impaired glucose tolerance (IGT) and gestational diabetes mellitus (GDM), their effect on pregnancy and their association with adverse obstetric outcomes. A cross-sectional study was performed on 345 pregnant women, who were screened between the 24th and 28th gestational week with a 75-g oral glucose tolerance test following abnormal results at 1 h after a 50-g oral glucose challenge test. The obstetric outcomes were recorded along with plasma glucose and insulin levels, homeostasis model assessment of insulin resistance (HOMA-IR) and homeostasis model assessment of β-cell function index (HOMA-βCFI) and 50 subjects were excluded due to incomplete data recovery. Of the 295 pregnant women, 18.6% (55/295) were diagnosed with GDM and 32% (95/295) with IGT. The GDM group exhibited significantly higher fasting and 1-h blood glucose concentrations compared to the normal glucose tolerance (NGT) and IGT groups (P<0.01). The 2- and 3-h insulin values of the NGT group were significantly lower compared to those of the GDM group (P<0.05, P<0.01). In the IGT group, the 2-h insulin values were higher compared to the NGT group and the 3-h values were significantly higher (P<0.01), similar to the GDM group. There was a tendency for progressively decreased β-cell function and increased HOMA-IR from the NGT to the IGT to the GDM group. The adverse outcomes of pregnancy-induced hypertension, fetal distress, neonatal hyperbilirubinemia, preterm delivery, macrosomia and cesarean delivery indicated an association with HOMA-βCFI and HOMA-IR. In conclusion, these findings suggest a clinical significance of β-cell dysfunction in women with gestational IGT.

High glucose levels reduce fatty acid oxidation and increase triglyceride accumulation in human placenta

Placentas of women with gestational diabetes mellitus (GDM) exhibit an altered lipid metabolism. The mechanism by which GDM is linked to alterations in placental lipid metabolism remains obscure. We hypothesized that high glucose levels reduce mitochondrial fatty acid oxidation (FAO) and increase triglyceride accumulation in human placenta. To test this hypothesis, we measured FAO, fatty acid esterification, de novo fatty acid synthesis, triglyceride levels, and carnitine palmitoyltransferase activities (CPT) in placental explants of women with GDM or no pregnancy complication. In women with GDM, FAO was reduced by ~30% without change in mitochondrial content, and triglyceride content was threefold higher than in the control group. Likewise, in placental explants of women with no complications, high glucose levels reduced FAO by ~20%, and esterification increased linearly with increasing fatty acid concentrations. However, de novo fatty acid synthesis remained unchanged between high and low glucose levels. In addition, high glucose levels increased triglyceride content approximately twofold compared with low glucose levels. Furthermore, etomoxir-mediated inhibition of FAO enhanced esterification capacity by ~40% and elevated triglyceride content 1.5-fold in placental explants of women, with no complications. Finally, high glucose levels reduced CPT I activity by ~70% and phosphorylation levels of acetyl-CoA carboxylase by ~25% in placental explants of women, with no complications. We reveal an unrecognized regulatory mechanism on placental fatty acid metabolism by which high glucose levels reduce mitochondrial FAO through inhibition of CPT I, shifting flux of fatty acids away from oxidation toward the esterification pathway, leading to accumulation of placental triglycerides.

Prevalence of gestational diabetes mellitus and its outcome in western Rajasthan

BACKGROUND

Gestational diabetes mellitus (GDM) is a metabolic disorder defined as glucose intolerance with the onset or first recognition during pregnancy. Women with GDM are at increased risk for adverse obstetric and perinatal outcome. Hence, it is imperative that an early detection and management of the disease is done to ensure better maternal and fetal outcomes.

AIMS

This study was done to evaluate the prevalence of gestational diabetes using diabetes in pregnancy Study Group India (DIPSI) criteria and further assess its feto-maternal outcome in western Rajasthan.

MATERIALS AND METHODS

This study was carried out in 500 patients between 24 and 28 weeks of gestation, attending the antenatal outdoor. These patients were given 75 g oral glucose irrespective of the meals and their plasma glucose was estimated at 2 h. Patients with plasma glucose values ΃140 mg/dl were labeled as GDM and the rest as the control or the non-GDM group. All GDM patients were followed up and treated with diet and/or insulin therapy till delivery to know maternal and fetal outcomes.

RESULTS

The prevalence of GDM in this study was 6.6%. Maternal and fetal complications in the GDM group were much higher than in the non-GDM group. Hypertension, vaginal candidiasis, and abruptio placentae were the common maternal complications, while macrosomia and stillbirths occurred in the fetuses.

CONCLUSION

GDM as a disease entity adversely affects maternal and fetal outcomes. This also builds a strong case for following DIPSI guidelines in diagnosis and management of GDM.

Epigenetics of gestational diabetes mellitus and offspring health: the time for action is in early stages of life

The epidemic increase of type 2 diabetes and obesity in developed countries cannot be explained by overnutrition, physical inactivity and/or genetic factors alone. Epidemiologic evidence suggests that an adverse intrauterine environment, in particular a shortage or excess of nutrients is associated with increased risks for many complex diseases later in life. An impressive example for the 'fetal origins of adult disease' is gestational diabetes mellitus which usually presents in 1% to >10% of third trimester pregnancies. Intrauterine hyperglycemia is not only associated with increased perinatal morbidity and mortality, but also with increased lifelong risks of the exposed offspring for obesity, metabolic, cardiovascular and malignant diseases. Accumulating evidence suggests that fetal overnutrition (and similarly undernutrition) lead to persistent epigenetic changes in developmentally important genes, influencing neuroendocrine functions, energy homeostasis and metabolism. The concept of fetal programming has important implications for reproductive medicine. Because during early development the epigenome is much more vulnerable to environmental cues than later in life, avoiding adverse environmental factors in the periconceptional and intrauterine period may be much more important for the prevention of adult disease than any (i.e. dietetic) measures in infants and adults. A successful pregnancy should not primarily be defined by the outcome at birth but also by the health status in later life.

Comparison of the serum iron, ferritin levels and total iron-binding capacity between pregnant women with and without gestational diabetes

BACKGROUND

Gestational diabetes mellitus (GDM) is the most common metabolic disorder during pregnancy. GDM causes substantial morbidity and mortality and long- term complications. GDM-related risk factors have not been completely identified yet. Some studies have found relationship between increased serum ferritin and impaired oral glucose tolerance test but the relationship between serum ferritin and risk of GDM has been controversial. The aim of the study was to determine serum iron and ferritin levels and total iron binding capacity (TIBC) in women with GDM and comparison with normal pregnant women.

MATERIALS AND METHODS

This case-control study was performed among 200 pregnant women (case = 100, control = 100) who were referred to Yahya-Nejad Hospital in the second trimester in Babol from 2008 to 2009. GDM was diagnosed by impaired OGTT based on Carpenter and Coustan criteria. The 2 groups were matched in age, gestational age and parity.

RESULTS

High serum ferritin level increased the risk of gestational diabetes to 2.4-fold [OR = 2.4 (0.83-6.9) CI = 95% (P = 0.10)], while in those with low ferritin levels, the risk of developing gestational diabetes was reduced to 82% [OR = 0.8 with (0.08-0.37) CI = 95% (P = 0.001)]. Using the logistic regression model, after adjustment for BMI, the OR was 2.37 [(0.80-7.01) CI = 95% (P = 0.11)] for low ferritin level and OR = 0.20 [(0.09-0.44) CI = 95% (P = 0.0001)] for high ferritin level, which was statistically significant.

CONCLUSION

The serum ferritin level was markedly higher in women with gestational diabetes than in normal pregnant women; therefore, high ferritin can be regarded as a significant risk factor for the development of gestational diabetes.

Inflammation and impaired endothelium-dependant vasodilatation in non obese women with gestational diabetes mellitus: preliminary results

BACKGROUND

To evaluate whether abnormal endothelial function, a common finding in gestational diabetes mellitus (GDM) pregnancies, can be explained by inflammatory cytokines.

METHODS

Forearm skin blood flow (FSBF), into response to acetylcholine (Ach) (endothelium-dependent vasodilatation), were measured in 24 pregnant control subjects and 28 gestational diabetes mellitus (GDM) women, in the third trimester of gestation. A fasting glycemic and lipidic panel was obtained, and inflammatory cytokines (TNF-α and IL-6) and adiponectin were also determined.

RESULTS

FSBF is significantly reduced in GDM group compared with control subjects (344.59 ± 57.791 vs.176.38 ± 108.52, P < 0.05). Among all subjects, FSBF showed a strong negative correlation with TNF-α and IL-6 (r = -0.426, P < 0.0001 and r = -0.564, P < 0.0001, respectively) and positive correlation with adiponectin (r = 0.468, P < 0.0001).

CONCLUSIONS

Endothelial function, an early marker of macrovascular disease, is present in non-obese pregnancies complicated by GDM. This alteration seems to be directly related to inflammatory status, which may represent a patho-physiological link between GDM and type 2 diabetes and, later on, metabolic syndrome.

Growth factors in preeclampsia: a vascular disease model. A failed vasodilation and angiogenic challenge from pregnancy onwards?

Preeclampsia is the major cause of maternofetal and neonatal morbi-mortality including intrauterine growth retardation, miscarriages and stillbirths. Inadequate vascular dilation and angiogenesis represent the crucial underlying defect of gravidic hypertension, denoting a failed response to the vasodilatory and pro-angiogenic challenge imposed by pregnancy, especially if multifetal. A similar pathogenesis appears involved in gestational diabetes. In this review we aimed to provide a hint on understanding the deeply involved angiogenic disorders which eventually culminate in utero-placental failure. The key players in these complex processes may be found in an intricate network of growth factors (GFs) and GF inhibitors, controlled by several vascular risk factors modulated by environment and genes, which eventually impact on early and late cardiovascular outcomes of mother and fetus.

Global methylation in the placenta and umbilical cord blood from pregnancies with maternal gestational diabetes, preeclampsia, and obesity

Emerging evidence indicates that maternal medical risk during pregnancy, such as gestational diabetes mellitus (GDM), preeclampsia, and obesity, predisposes the offspring to suboptimal development. However, the underlying biological/epigenetic mechanism in utero is still unknown. The current pilot study (N = 50) compared the levels of global methylation in the placenta and umbilical cord blood among women with and without each risk condition (GDM, preeclampsia, and obesity) and explored whether the levels of global methylation were associated with fetal/infant growth. Results show that global methylation levels in the placenta were lower in patients with gestational diabetes (P = .003) and preeclampsia (P = .05) but higher with obesity (P = .01). Suggestive negative associations were found between global methylation level in the placenta and infant body length and head circumference. While preliminary, it is possible that the placenta tissue, but not umbilical cord blood, may be epigenetically programmed by maternal GDM, preeclampsia, and obesity to carry out its own specific functions that influence fetal growth.

Potential role and therapeutic interests of myo-inositol in metabolic diseases

Several inositol isomers and in particular myo-inositol (MI) and D-chiro-inositol (DCI), were shown to possess insulin-mimetic properties and to be efficient in lowering post-prandial blood glucose. In addition, abnormalities in inositol metabolism are associated with insulin resistance and with long term microvascular complications of diabetes, supporting a role of inositol or its derivatives in glucose metabolism. The aim of this review is to focus on the potential benefits of a dietary supplement of myo-inositol, by far the most common inositol isomer in foodstuffs, in human disorders associated with insulin resistance (polycystic ovary syndrome, gestational diabetes mellitus or metabolic syndrome) or in prevention or treatment of some diabetic complications (neuropathy, nephropathy, cataract). The relevance of such a nutritional strategy will be discussed for each context on the basis of the clinical and/or animal studies. The dietary sources of myo-inositol and its metabolism from its dietary uptake to its renal excretion will be also covered in this review. Finally, the actual insights into inositol insulin-sensitizing effects will be addressed and in particular the possible role of inositol glycans as insulin second messengers.

Low glycaemic index diets improve glucose tolerance and body weight in women with previous history of gestational diabetes: a six months randomized trial

BACKGROUND

Gestational Diabetes Mellitus (GDM) increases risks for type 2 diabetes and weight management is recommended to reduce the risk. Conventional dietary recommendations (energy-restricted, low fat) have limited success in women with previous GDM. The effect of lowering Glycaemic Index (GI) in managing glycaemic variables and body weight in women post-GDM is unknown.

OBJECTIVE

To evaluate the effects of conventional dietary recommendations administered with and without additional low-GI education, in the management of glucose tolerance and body weight in Asian women with previous GDM.

METHOD

Seventy seven Asian, non-diabetic women with previous GDM, between 20- 40y were randomised into Conventional healthy dietary recommendation (CHDR) and low GI (LGI) groups. CHDR received conventional dietary recommendations only (energy restricted, low in fat and refined sugars, high-fibre). LGI group received advice on lowering GI in addition. Fasting and 2-h post-load blood glucose after 75 g oral glucose tolerance test (2HPP) were measured at baseline and 6 months after intervention. Anthropometry and dietary intake were assessed at baseline, three and six months after intervention. The study is registered at the Malaysian National Medical Research Register (NMRR) with Research ID: 5183.

RESULTS

After 6 months, significant reductions in body weight, BMI and waist-to-hip ratio were observed only in LGI group (P<0.05). Mean BMI changes were significantly different between groups (LGI vs. CHDR: -0.6 vs. 0 kg/m2, P= 0.03). More subjects achieved weight loss ≥5% in LGI compared to CHDR group (33% vs. 8%, P=0.01). Changes in 2HPP were significantly different between groups (LGI vs. CHDR: median (IQR): -0.2(2.8) vs. +0.8 (2.0) mmol/L, P=0.025). Subjects with baseline fasting insulin≥2 μIU/ml had greater 2HPP reductions in LGI group compared to those in the CHDR group (-1.9±0.42 vs. +1.31±1.4 mmol/L, P<0.001). After 6 months, LGI group diets showed significantly lower GI (57±5 vs. 64±6, P<0.001), GL (122±33 vs. 142±35, P=0.04) and higher fibre content (17±4 vs.13±4 g, P<0.001). Caloric intakes were comparable between groups.

CONCLUSION

In women post-GDM, lowering GI of healthy diets resulted in significant improvements in glucose tolerance and body weight reduction as compared to conventional low-fat diets with similar energy prescription.

Pragmatic controlled trial to prevent childhood obesity in maternity and child health care clinics: pregnancy and infant weight outcomes (the VACOPP Study)

BACKGROUND

According to current evidence, the prevention of obesity should start early in life. Even the prenatal environment may expose a child to unhealthy weight gain; maternal gestational diabetes is known to be among the prenatal risk factors conducive to obesity. Here we report the effects of antenatal dietary and physical activity counselling on pregnancy and infant weight gain outcomes.

METHODS

The study was a non-randomised controlled pragmatic trial aiming to prevent childhood obesity, the setting being municipal maternity health care clinics. The participants (n = 185) were mothers at risk of developing gestational diabetes mellitus and their offspring. The children of the intervention group mothers were born between 2009 and 2010, and children of the control group in 2008. The intervention started between 10-17 gestational weeks and consisted of individual counselling on diet and physical activity by a public health nurse, and two group counselling sessions by a dietician and a physiotherapist. The expectant mothers also received a written information leaflet to motivate them to breastfeed their offspring for at least 6 months. We report the proportion of mothers with pathological glucose tolerance at 26-28 weeks' gestation, the mother's gestational weight gain (GWG) and newborn anthropometry. Infant weight gain from 0 to 12 months of age was assessed as weight-for-length standard deviation scores (SDS) and mixed effect linear regression models.

RESULTS

Intervention group mothers had fewer pathological oral glucose tolerance test results (14.6% vs. 29.2%; 95% CI 8.9 to 23.0% vs. 20.8 to 39.4%; p-value 0.016) suggesting that the intervention improved gestational glucose tolerance. Mother's GWG, newborn anthropometry or infant weight gain did not differ significantly between the groups.

CONCLUSION

Since the intervention reduced the prevalence of gestational diabetes mellitus, it may have the potential to diminish obesity risk in offspring. However, results from earlier studies suggest that the possible effect on the offspring's weight gain may manifest only later in childhood.

TRIAL REGISTRATION

Clinical Trials gov: NCT00970710.

Genetic variants and the risk of gestational diabetes mellitus: a systematic review

BACKGROUND

Several studies have examined associations between genetic variants and the risk of gestational diabetes mellitus (GDM). However, inferences from these studies were often hindered by limited statistical power and conflicting results. We aimed to systematically review and quantitatively summarize the association of commonly studied single nucleotide polymorphisms (SNPs) with GDM risk and to identify important gaps that remain for consideration in future studies.

METHODS

Genetic association studies of GDM published through 1 October 2012 were searched using the HuGE Navigator and PubMed databases. A SNP was included if the SNP-GDM associations were assessed in three or more independent studies. Two reviewers independently evaluated the eligibility for inclusion and extracted the data. The allele-specific odds ratios (ORs) and 95% confidence intervals (CIs) were pooled using random effects models accounting for heterogeneity.

RESULTS

Overall, 29 eligible articles capturing associations of 12 SNPs from 10 genes were included for the systematic review. The minor alleles of rs7903146 (TCF7L2), rs12255372 (TCF7L2), rs1799884 (-30G/A, GCK), rs5219 (E23K, KCNJ11), rs7754840 (CDKAL1), rs4402960 (IGF2BP2), rs10830963 (MTNR1B), rs1387153 (MTNR1B) and rs1801278 (Gly972Arg, IRS1) were significantly associated with a higher risk of GDM. Among them, genetic variants in TCF7L2 showed the strongest association with GDM risk, with ORs (95% CIs) of 1.44 (1.29-1.60, P < 0.001) per T allele of rs7903146 and 1.46 (1.15-1.84, P = 0.002) per T allele of rs12255372.

CONCLUSIONS

In this systematic review, we found significant associations of GDM risk with nine SNPs in seven genes, most of which have been related to the regulation of insulin secretion.

Effect of a low glycaemic index diet in gestational diabetes mellitus on post-natal outcomes after 3 months of birth: a pilot follow-up study

A low glycaemic index (LGI) diet during pregnancy complicated by gestational diabetes mellitus (GDM) may offer benefits to the mother and infant pair beyond those during pregnancy. We aimed to investigate the effect of an LGI diet during pregnancy complicated with GDM on early post-natal outcomes. Fifty-eight women (age: 23-41 years; mean ± SD pre-pregnancy body mass index: 24.5 ± 5.6 kg m(-2) ) who had GDM and followed either an LGI diet (n = 33) or a conventional high-fibre diet (HF; n = 25) during pregnancy had a 75-g oral glucose tolerance test and blood lipid tests at 3 months post-partum. Anthropometric assessments were conducted for 55 mother-infant pairs. The glycaemic index of the antenatal diets differed modestly (mean ± SD: 46.8 ± 5.4 vs. 52.4 ± 4.4; P < 0.001), but there were no significant differences in any of the post-natal outcomes. In conclusion, an LGI diet during pregnancy complicated by GDM has outcomes similar to those of a conventional healthy diet. Adequately powered studies should explore the potential beneficial effects of LGI diet on risk factors for chronic disease.

An evaluation of Croí MyAction community lifestyle modification programme compared to standard care to reduce progression to diabetes/pre-diabetes in women with prior gestational diabetes mellitus (GDM): study protocol for a randomised controlled trial

BACKGROUND

Universal screening using the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria has identified a prevalence of gestational diabetes mellitus (GDM) of 12.4% in women living in Ireland. Women with prior GDM are at increased risk of developing type 2 diabetes later in life. A number of risk factors linked to the development of type 2 diabetes are potentially modifiable through lifestyle and behaviour changes, and medical management. No previous Irish studies have adequately investigated the efficacy of lifestyle intervention programmes in reducing these risk factors in women with prior GDM. Through a two-group, parallel randomised controlled trial (RCT), this study aims to assess the clinical impact, cost-effectiveness and psychological experience of the Croí MyAction intensive lifestyle modification programme for women with prior GDM.

METHODS/DESIGN

A total of 54 women with a history of GDM and persistent post-partum glucose dysfunction (impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)), are randomly assigned to a control arm (n=27) or to the Croí MyAction intervention group (n=27). The control arm receives usual health care advice--written information on diet and lifestyle changes for reducing diabetes risks and visits with general practitioners as required. The intervention group receives usual health care as per the control group in addition to attending a 12-week intensive lifestyle modification programme known as Croí MyAction. Croí MyAction involves 2.5 hour sessions once per week (for 12 weeks) comprising a group exercise programme, group health promotion or education seminars, and one-to-one meetings with a multidisciplinary health care team to personalise risk factor reductions. Randomisation and allocation to the intervention arms is carried out by an independent researcher, ensuring that the allocation sequence is concealed from study researchers until the interventions are assigned. The primary analysis is based on glucose dysfunction, comparing a mean reduction in fasting plasma glucose (FPG) levels on a 75 gram oral glucose tolerance test (OGTT) in the two groups at a one-year, post-intervention follow-up. The trial is funded by the Irish Health Research Board (HRB). Ethics approval was obtained on 27 March 2012 from the Clinical Research Ethics Committee, Galway University Hospitals, Health Service Executive of Ireland (Ref: C.A.691).

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41202110.

The relationship between low maternal serum 25-hydroxyvitamin D levels and gestational diabetes mellitus according to the severity of 25-hydroxyvitamin D deficiency

OBJECTIVE

To assess the relationship between low maternal serum 25-hydroxyvitamin D levels and gestational diabetes mellitus in Turkish pregnant women according to the severity of 25-hydroxyvitamin D deficiency and assess intact parathyroid hormone levels in women with gestational diabetes mellitus and controls with low and sufficient 25-hydroxyvitamin D levels.

METHODS

We analyzed serum 25-hydroxyvitamin D and intact parathyroid hormone levels in 234 women with gestational diabetes mellitus and 168 controls. To define the deficiency status, 25-hydroxyvitamin D levels were further classified into severely deficient, deficient, insufficient and sufficient groups.

RESULTS

Women with gestational diabetes mellitus had significantly lower 25-hydroxyvitamin D levels compared to controls (30.8±16.3 vs. 36.0±16.2 nmol/L). However, when subgroups of 25-hydroxyvitamin D were analyzed, gestational diabetes mellitus was significantly more common only in women with severely deficient 25-hydroxyvitamin D levels. After adjusting for covariates, only severely deficient 25-hydroxyvitamin D levels were independently associated with an increased relative risk of gestational diabetes mellitus. The relative risk of gestational diabetes mellitus in women with insufficient and deficient 25-hydroxyvitamin D levels was not statistically significant. Intact parathyroid hormone concentrations were also significantly higher in women with gestational diabetes mellitus compared to the controls (45.3±26.2 vs. 38.7±27.6 pg/ml).

CONCLUSIONS

The results obtained from this study provide novel data indicating that only severely deficient maternal serum 25-hydroxyvitamin D levels are significantly associated with an elevated relative risk of gestational diabetes mellitus, even after adjusting for established risk factors of gestational diabetes mellitus.

Intrahepatic fat is increased in the neonatal offspring of obese women with gestational diabetes

OBJECTIVES

To assess precision magnetic resonance imaging in the neonate and determine whether there is an early maternal influence on the pattern of neonatal fat deposition in the offspring of mothers with gestational diabetes mellitus (GDM) and obesity compared with the offspring of normal-weight women.

STUDY DESIGN

A total of 25 neonates born to normal weight mothers (n = 13) and to obese mothers with GDM (n = 12) underwent magnetic resonance imaging for the measurement of subcutaneous and intra-abdominal fat and magnetic resonance spectroscopy for the measurement of intrahepatocellular lipid (IHCL) fat at 1-3 weeks of age.

RESULTS

Infants born to obese/GDM mothers had a mean 68% increase in IHCL compared with infants born to normal-weight mothers. For all infants, IHCL correlated with maternal prepregnancy body mass index but not with subcutaneous adiposity.

CONCLUSION

Deposition of liver fat in the neonate correlates highly with maternal body mass index. This finding may have implications for understanding the developmental origins of childhood nonalcoholic fatty liver disease.

Caspase 3 activation and PARP cleavage in lymphocytes from newborn babies of diabetic mothers with unbalanced glycaemic control

Several epidemiological studies showed that gestational diabetes mellitus is the most frequent metabolic disorder of pregnancy, the pathogenesis of which has yet to be completely clarified. The aim of this study was to investigate the presence and processing of caspase 3 (Casp3) and poly(ADP-ribose) polymerase 1 (PARP1) in cord blood lymphocytes as markers of apoptosis in relation to glycaemic control during intrauterine life. Our results showed a specific positive correlation between the levels of active Casp3 (17-19 kDa) and the inactive form of PARP1 (89 kDa) in lymphocytes isolated from newborn babies of diabetic women with unbalanced glycaemic control, with a direct correlation between the activation of casp3 and the inactivation of PARP1, that makes lymphocytes unresponsive towards lipopolysaccharide stimulation, highlighting an altered functional response. Besides more studies are required to fully correlate the activation of the apoptotic process during the intrauterine life with the foetal health later in life, our study indicates that a cord blood lymphocyte, an easily accessible source, is informative about the activation of apoptotic stimuli in circulating cells of newborn babies in relation to the glycaemic control reached by the mother during pregnancy.

Cardiometabolic consequences of gestational dysglycemia

The development of gestational diabetes and even milder forms of dysglycemia during pregnancy represents a maternal phenotype at increased subsequent risk for developing type 2 diabetes mellitus, metabolic syndrome, and, with time, overt cardiovascular disease. A careful and systematic dissection of the hormonal, metabolic, and vascular changes occurring in such women during pregnancy and over the postpartum years provides a unique opportunity to identify conventional and novel conditions and biomarkers whose modification may attenuate adverse long-term outcomes, particularly cardiovascular risk. The purpose of this review is to summarize current understanding of the magnitude of such risk and its potential causes, with a particular focus on postpartum alterations in endothelial and vascular smooth muscle responsiveness.

Association of variants in PPARγ², IGF2BP2, and KCNQ1 with a susceptibility to gestational diabetes mellitus in a Korean population

PURPOSE

Patients with gestational diabetes mellitus (GDM) have been reported to exhibit the same genetic susceptibility as that observed in those with type 2 diabetes mellitus (T2DM). Recent polymorphism studies have shown that several genes are related to T2DM and GDM. The aim of this study was to examine whether certain candidate genes, previously shown to be associated with T2DM, also offer a specific genetic predisposition to GDM.

MATERIALS AND METHODS

The current study was conducted in 136 Korean pregnant women, who gave birth at Gil Hospital, from October 2008 to May 2011. These study subjects included 95 subjects with GDM and 41 non-diabetic controls. We selected the specific genes of PPARγ², IGF2BP2, and KCNQ1 for study and amplified them using the polymerase chain reaction. This was followed by genotyping for single nucleotide polymorphisms. We then compared the genotype frequencies between patients with GDM and non-diabetic controls using the χ² test. We obtained and analyzed clinical information using Student's t-test, and statistical analyses were conducted using logistic regression with SPSS Statistics software, version 19.0.

RESULTS

Significant differences were observed in maternal age, body mass index, weight gain and weight at time of delivery between the groups compared. Among pregnant women, polymorphisms in PPARγ² and IGF2BP2 were shown to be highly correlated with GDM occurrence, whereas no correlation was found for KCNQ1 polymorphisms.

CONCLUSION

Our results indicated that genetic polymorphisms could also be of value in predicting the occurrence and diagnosis of GDM.

Gestational diabetes mellitus (GDM) decreases butyrylcholinesterase (BChE) activity and changes its relationship with lipids

Many conditions interfere with butyrylcholinesterase (BChE) activity, e.g., pregnancy or presence of the BCHE gene variant -116A can decrease activity whereas obesity and types I and II diabetes mellitus can increase activity. In this study, we examined BChE activity, -116A and 1615A BCHE gene variants, and anthropometric and biochemical variables associated with diabetes in patients with gestational diabetes mellitus (GDM) and in healthy pregnant women. BChE activity was measured spectrophotometrically using propionylthiocholine as substrate and genotyping of the -116 and 1615 sites of the BCHE gene was done with a TaqMan SNP genotyping assay. Three groups were studied: 150 patients with GDM, 295 healthy pregnant women and 156 non-pregnant healthy women. Mean BChE activity was significantly lower in healthy pregnant women than in women from the general population and was further reduced in GDM patients. BChE activity was significantly reduced in carriers of -116A in GDM patients and healthy pregnant women. Although GDM patients had a significantly higher mean body mass index (BMI) and triglycerides than healthy pregnant women, they had lower mean BChE activity, suggesting that the lowering effect of GDM on BChE activity was stronger than the characteristic enhancing effect of increased BMI and triglycerides.

Mitochondrial DNA copy number and oxidative DNA damage in placental tissues from gestational diabetes and control pregnancies: a pilot study

BACKGROUND

Available evidence supports the role of reactive oxygen species in the pathogenesis of placental insufficiency, gestational diabetes mellitus (GDM), and other pregnancy complications. Abnormal placental mitochondrial function resulting from reactive oxygen species may also be an important precedent of adverse perinatal outcomes.

METHODS

We investigated the association of placental oxidative stress with placental mitochondrial DNA (mtDNA) copy number, an indicator of placental mitochondrial density and possible mitochondrial dysfunction, using samples collected from GDM cases and controls. 8-hydroxy-2'-deoxyguanosine (8-OHdG), a marker of oxidative DNA damage, was measured in placentas of 19 GDM cases and 21 controls using a competitive immunoassay. Placental mtDNA copy number was determined using real-time quantitative PCR. Bivariate and multivariable linear regression procedures were used to evaluate associations of these two biomarkers.

RESULTS

Placental DNA oxidation was positively associated with mtDNA copy number in both GDM and control placentas. After adjusting for maternal age, pre-pregnancy body mass index and gestational age at delivery, mtDNA copy number increased (beta = 67.0; 95% CI 27.8 - 106.2, p = 0.001) for every 0.1 ng/microg increase of placental 8-OHdG among GDM cases and controls.

CONCLUSIONS

These cross sectional data suggest an association of placental mtDNA copy number with oxidative stress. The consequences of placental oxidative stress and mitochondrial dysfunction on the course and outcomes of pregnancy remain to be elucidated in larger prospective studies.

Awareness of gestational diabetes mellitus among antenatal women in a primary health center in South India

BACKGROUND

Gestational diabetes mellitus (GDM) is a perfect window of opportunity for the prevention of DM in two generations, and its incidence is increasing in our country. Awareness of the condition among antenatal women will translate into prevention and early diagnosis of the disease. This study was done to determine the awareness of GDM among all the antenatal women who attend a Primary Health Center (PHC) for antenatal care.

MATERIALS AND METHODS

A pretested questionnaire consisting of details on background characteristics, 12 questions focusing on Type 2 DM and GDM, and a question on the source of knowledge was administered to all women attending the antenatal clinic. Their responses were scored and the women were graded as having good, fair, or poor knowledge about GDM.

RESULTS

One hundred and twenty antenatal women participated in the study. Mean age of the women was 23.8 years (SD: 2.94). Overall, 17.5% women had good knowledge, 56.7% had fair knowledge, and 25.8% women had poor knowledge about GDM. The major sources of awareness of GDM were reported to be television/radio, neighbors/friends, and family members.

DISCUSSION

Only a small proportion of rural antenatal women had good knowledge about GDM. The awareness that untreated GDM may pose a risk to the unborn child was high among the study women. Health care workers have to play a greater role in bringing about awareness about GDM among antenatal women.