Gestational Diabetes and Long-Term Cardiometabolic Health

Prediction of Gestational Diabetes Mellitus (GDM) risk in early pregnancy based on clinical data and ultrasound information: a nomogram

BACKGROUND

Gestational diabetes mellitus (GDM) is one of the most common complications during pregnancy and has been on a continuous increase in recent years. This study aimed to establish a combined prediction model for the risk of GDM and to provide more reliable reference information for non-invasive assessment of GDM in clinical practice.

METHODS

This study retrospectively collected clinical data and ultrasound information of 122 pregnant women who underwent fetal nuchal translucency screening, which divided into 36 cases of the GDM group and 86 cases of the non-gestational diabetes mellitus(NGDM) group. The collected clinical data and ultrasound information were analyzed using Student's t-test and Wilcoxon W test for univariate analysis. Independent risk factors for patients with GDM were screened through binary logistic regression analysis. A model was established based on the screened results, and the diagnostic performance of different models was evaluated by drawing the receiver operating characteristic curve(ROC). The optimal prediction model was selected, and the calibration curve and clinical decision curve were drawn to evaluate the goodness of fit and clinical application efficiency of the model.

RESULTS

Univariate results showed that age, body mass index(BMI), number of abortions, gravidity, placental volume(PV), vascularization index(VI), flow index(FI), and vascularization flow index(VFI) all had statistically significant differences between the GDM and NGDM groups(p < 0.05). Binary logistic regression analysis showed that BMI, number of abortions, PV, VI, and FI were independent risk factors for the development of GDM in pregnant women (p < 0.05). Based on these results, five prediction models were established in this study. Their area under the ROC curve(AUC) were 0.67, 0.80, 0.80, 0.87, and 0.85, respectively. The model combining clinical data with 30° ultrasound data had the highest AUC, so we constructed a nomogram for this model. The results of its calibration curve showed that the model had a good fit, and the results of the clinical decision curve showed that the model had good clinical application efficiency.

CONCLUSION

The nomogram model combining clinical data with 30° ultrasound data has good accuracy and clinical application value for predicting the risk of GDM.

SPARK: an mHealth intervention for self-management and treatment of gestational diabetes mellitus in Sweden - protocol for a randomised controlled trial

INTRODUCTION

Gestational diabetes mellitus (GDM) is increasingly becoming a serious public health challenge. Innovative, effective and scalable lifestyle interventions to support women with GDM to manage their condition and prevent adverse obstetric and neonatal outcomes as well as later morbidity are required. This study aims to evaluate whether a novel, multilingual and scalable mobile health (mHealth) intervention (SPARK; SmartPhone App for gestational diabetes patients suppoRting Key lifestyle behaviours and glucose control) can improve self-management and treatment of GDM and prevent adverse maternal and offspring outcomes.

METHODS/ANALYSES

SPARK is a multicentre two-arm randomised controlled trial recruiting women diagnosed with GDM in south-eastern Sweden. A total of 412 women will be randomised to either standard care (control) or the SPARK intervention. The SPARK online platform (accessed through a mobile app) provides a behaviour change programme for healthy eating, physical activity and glycaemic control. To increase reach, SPARK is available in Swedish, English, Arabic and Somali. SPARK also comes with a clinician portal where healthcare professionals monitor and intervene when glycaemic control is unsatisfactory (above certain cut-offs). Primary outcomes are glycaemic control that is, time in range and HbA1c, while diet, physical activity (ActiGraph), gestational weight gain, metabolic and inflammatory biomarkers in weeks 37-38, adherence to protocol for daily glucose sampling, as well as adverse obstetric and neonatal outcomes are secondary outcomes. Secondary outcomes also include cardiometabolic risk evaluation, physical activity and healthy eating behaviours 1 year postpartum. A health economic evaluation of SPARK vs standard care will also be conducted.

ETHICS AND DISSEMINATION

This study has been approved by the Swedish Ethical Review Authority (2021-06627-01; 2022-03842-02; 2023-05911-02). Results will be disseminated through scientific papers in peer-reviewed journals, posts in traditional and social media, and presentations at scientific and healthcare professionals' conferences.

TRIAL REGISTRATION NUMBER

This trial was registered at the ClinicalTrials.gov register platform (ID NCT05348863) 27 April 2022.

Global research trends and hotspots in gestational diabetes and long-term cardiovascular health: A bibliometric analysis

AIMS

To identify emerging trends and hotspots in research regarding cardiovascular disease (CVD) risk linked to gestational diabetes mellitus (GDM).

METHODS

A systematic bibliometric review of the literature on the risk of long-term CVD in patients with GDM between 1990 and 2022 from the Web of Science Core Collection (WoSCC) was performed by using Citespace and VOSviewer.

RESULTS

This analysis gathered a total of 1185 articles, with 77 publications in 2019 and 119 in 2022, demonstrating a steady growth in the amount of research on the relationship between GDM and CVD in recent years. The United States of America (USA) led in national publications, followed by the United Kingdom (UK) and Canada. Key institutions included Harvard University, the University of Toronto, and the University of Oslo, with Prof. Ravi Retnakaran and Prof. Jane W. Rich-Edwards being prominent figures. The most productive journal was the Journal of Clinical Endocrinology &Metabolism, while Diabetes Care was the most influential and most co-cited journal. Common terms over the last 20 years included "risk," "type 2 diabetes," "cardiovascular disease," and "gestational diabetes," with recent focus shifting towards "prevention," "gene expression," and "DNA methylation".

CONCLUSION

This is the first bibliometric analysis linking CVD and GDM. Future research should investigate pathways between GDM and CVD, emphasizing gene expression and inflammation, while advocating for collaborative prevention strategies.

Highs and Lows

In this narrative medicine essay, a transplant hepatology fellow whose gestational diabetes progressed to type 1 diabetes finds robust online support groups that have helped her navigate her new reality.

Deciphering DNA Methylation in Gestational Diabetes Mellitus: Epigenetic Regulation and Potential Clinical Applications

Gestational diabetes mellitus (GDM) represents a prevalent complication during pregnancy, exerting both short-term and long-term impacts on maternal and offspring health. This review offers a comprehensive outline of DNA methylation modifications observed in various maternal and offspring tissues affected by GDM, emphasizing the intricate interplay between DNA methylation dynamics, gene expression, and the pathogenesis of GDM. Furthermore, it explores the influence of environmental pollutants, maternal nutritional supplementation, and prenatal gut microbiota on GDM development through alterations in DNA methylation profiles. Additionally, this review summarizes recent advancements in DNA methylation-based diagnostics and predictive models in early GDM detection and risk assessment for subsequent type 2 diabetes. These insights contribute significantly to our understanding of the epigenetic mechanisms underlying GDM development, thereby enhancing maternal and fetal health outcomes and advocating further efforts in this field.

Motivational factors for dietary intake behavior in gestational diabetes mellitus: A cross-sectional study

Context

Decision-making behavior pertains to the cognitive process where a patient evaluates the advantages and disadvantages of health-related decisions, taking into account their personal preferences, values, and cognitive factors. This behavior is central to the successful implementation of clinical care. Effective decision-making enhances an individual's or organization's response to challenges and opportunities, improves problem-solving capabilities, reduces risks and uncertainties, and facilitates the attainment of desired outcomes.

Objective

The goal of this study was to investigate the current status of dietary choice decision-making in gestational diabetes mellitus and to analyze its influencing factors, and then to find the determining factors and give targeted nursing interventions in order to improve the dietary decision-making ability of gestational diabetes mellitus patients and further standardize their dietary patterns.

Methods

A cross-sectional research design was employed in this study. Convenience sampling was utilized to survey 539 GDM patients attending the obstetrics outpatient clinic and obstetrics ward of a tertiary hospital in Wuxi City, China, from March 2023 to July 2023. The survey instruments used were the General Information Questionnaire, the Motivation to Protect Pregnant Women with Gestational Diabetes Mellitus Dietary Intake Questionnaire, and the Conflict in Decision-Making Scale.

Results

The findings were derived from data collected from 539 GDM cases. The participants' ages ranged from 19 to 52 years, with a mean age of 31.53 ± 4.37 years. The scores for GDM disease perceived susceptibility were 15.200 ± 3.481, disease perceived severity 18.455 ± 4.670, internal reward 13.226 ± 4.275, external reward 8.278 ± 2.923, response efficacy 15.078 ± 3.889, self-efficacy 18.952 ± 4.800, cost of response 14.540 ± 5.227, and decision conflict questionnaire score 70.96 ± 11.78.

Conclusions

The study revealed that GDM patients exhibited a moderate level of decision-making dilemma. Notably, the patients' perceived susceptibility and severity of the disease, along with their response efficacy and self-efficacy, positively influenced their dietary decision-making abilities. Specifically, enhancing patients' awareness of their condition and boosting their self-efficacy significantly improved their decision-making capabilities. Conversely, internal and external rewards, as well as the cost of response, exerted a negative impact on GDM patients' decision-making abilities. Therefore, it is imperative to mitigate potential barriers in GDM patients' dietary intake behaviors, thereby enhancing their decision-making skills related to dietary intake.

Association between frailty and gestational diabetes mellitus: a bidirectional and multivariable Mendelian randomization study

Background

The causality between frailty and gestational diabetes mellitus (GDM) has not yet been fully explored. A potential bidirectional causality was also needed to be confirmed.

Methods

A bidirectional two-sample Mendelian randomization (MR) was conducted, with frailty-related data was collected from UK Biobank and TwinGen and GDM-related data was collected from the FinnGen consortium. We performed univariable and multivariable-adjusted MR with adjustments for body mass index (BMI). Several methodologies of MR were conducted to confirm the robustness of results.

Results

Frailty was significantly associated with elevated risks of GDM (OR, 3.563; 95% CI, 1.737 to 7.309; P< 0.001) and GDM was also significantly associated with elevated risks of frailty ( β , 0.087; 95% CI, 0.040 to 0.133; P< 0.001). There is no evidence demonstrating the existence of horizontal pleiotropy and heterogeneity. This association was robust after adjustments for BMI. The sensitivity analyses with Weighted median, Maximum likelihood, Penalised weighted median, MR Egger and MR PRESSO methods indicated consistent results.

Conclusion

Our study provides evidence of the bidirectional causal association between frailty and GDM from genetic perspectives, signaling that the identification and assessment of frailty should become a standard strategy during the early stages and care of gestational diabetes.

Association between gestational diabetes and cardiovascular disease within 24 months postpartum

BACKGROUND

Cardiovascular disease is the leading cause of death among women in the United States. It is well established that gestational diabetes mellitus is associated with an overall lifetime increased risk of cardiometabolic disease, even among those without intercurrent type 2 diabetes. However, the association between gestational diabetes mellitus and short-term risk of cardiovascular disease is unclear. Establishing short-term risks of cardiovascular disease for patients with gestational diabetes mellitus has significant potential to inform early screening and targeted intervention strategies to reduce premature cardiovascular morbidity among women.

OBJECTIVE

This study aimed to compare the risk of cardiovascular disease diagnosis in the first 24 months postpartum between patients with and without gestational diabetes mellitus.

STUDY DESIGN

Our longitudinal population-based study included pregnant individuals with deliveries from 2007 to 2019 in the Maine Health Data Organization's All Payer Claims Database. We excluded records with gestational age <20 weeks, non-Maine residence, multifetal gestation, no insurance in the month of delivery or the 3 months before pregnancy, an implausibly short interval until next pregnancy (<60 days), pregestational diabetes mellitus, and any prepregnancy diagnosis of the cardiovascular conditions being examined postpartum. Gestational diabetes mellitus and cardiovascular disease (heart failure, ischemic heart disease, arrhythmia/cardiac arrest, cardiomyopathy, cerebrovascular disease/stroke, and new chronic hypertension) were identified by International Classification of Diseases 9/10 diagnosis codes. Cox proportional hazards models were used to estimate hazard ratios, adjusting for potential confounding factors. We assessed whether the association between gestational diabetes mellitus and chronic hypertension was mediated by intercurrent diabetes mellitus.

RESULTS

Among the 84,746 pregnancies examined, the cumulative risk of cardiovascular disease within 24 months postpartum for those with vs without gestational diabetes mellitus was 0.13% vs 0.20% for heart failure, 0.16% vs 0.14% for ischemic heart disease, 0.60% vs 0.44% for cerebrovascular disease/stroke, 0.22% vs 0.16% for arrhythmia/cardiac arrest, 0.20% vs 0.20% for cardiomyopathy, and 4.19% vs 1.83% for new chronic hypertension. After adjusting for potential confounders, those with gestational diabetes had an increased risk of new chronic hypertension (adjusted hazard ratio, 1.56; 95% confidence interval, 1.32-1.86) within the first 24 months postpartum compared with those without gestational diabetes. There was no association between gestational diabetes and ischemic heart disease (adjusted hazard ratio, 0.75; 95% confidence interval, 0.34-1.65), cerebrovascular disease/stroke (adjusted hazard ratio, 1.13; 95% confidence interval, 0.78-1.66), arrhythmia/cardiac arrest (adjusted hazard ratio, 1.16; 95% confidence interval, 0.59-2.29), or cardiomyopathy (adjusted hazard ratio, 0.75; 95% confidence interval, 0.40-1.41) within the first 24 months postpartum. Those with gestational diabetes appeared to have a decreased risk of heart failure within 24 months postpartum (adjusted hazard ratio, 0.45; 95% confidence interval, 0.21-0.98). Our mediation analyses estimated that 28% of the effect of gestational diabetes on new chronic hypertension was mediated through intercurrent diabetes mellitus.

CONCLUSION

Patients with gestational diabetes mellitus have a significantly increased risk of new chronic hypertension as early as 24 months postpartum. Most of this effect was not due to the development of diabetes mellitus. Our findings suggest that all women with gestational diabetes need careful monitoring and screening for new chronic hypertension in the first 2 years postpartum.

Patient Priorities, Decisional Comfort, and Satisfaction with Metformin versus Insulin for the Treatment of Gestational Diabetes Mellitus

OBJECTIVE

 We compared patient priorities, decisional comfort, and satisfaction with treating gestational diabetes mellitus (GDM) with metformin versus insulin among pregnant individuals with GDM requiring pharmacotherapy.

STUDY DESIGN

 We conducted a cross-sectional study of patients' perspectives about GDM pharmacotherapy in an integrated prenatal and diabetes care program from October 19, 2022, to August 24, 2023. The exposure was metformin versus insulin as the initial medication decision. Outcomes included standardized measures of patient priorities, decisional comfort, and satisfaction about their medication decision.

RESULTS

 Among 144 assessed individuals, 60.4% were prescribed metformin and 39.6% were prescribed insulin. Minoritized individuals were more likely to receive metformin compared with non-Hispanic White individuals (34.9 vs. 17.5%; p = 0.03). Individuals who were willing to participate in a GDM pharmacotherapy clinical trial were more likely to receive insulin than those who were unwilling (30.4 vs. 19.5%; p = 0.02). Individuals receiving metformin were more likely to report prioritizing avoiding injections (62.4 vs. 19.3%; adjusted odds ratio [aOR]: 2.83; 95% confidence interval [CI]: 1.10-7.31), wanting to take a medication no more than twice daily (56.0 vs. 30.4%; aOR: 3.67; 95% CI: 1.56-8.67), and believing that both medications can equally prevent adverse pregnancy outcomes (70.9 vs. 52.6%; aOR: 2.67; 95% CI: 1.19-6.03). Conversely, they were less likely to report prioritizing a medication that crosses the placenta (39.1 vs. 82.5%; aOR: 0.09; 95% CI: 0.03-0.25) and needing supplemental insulin to achieve glycemic control (21.2 vs. 47.4%; aOR: 0.36; 95% CI: 0.15-0.90). Individuals reported similarly high (mean score > 80%) levels of decisional comfort, personal satisfaction with medication decision-making, and satisfaction about their conversation with their provider about their medication decision with metformin and insulin (p ≥ 0.05 for all).

CONCLUSION

 Individuals with GDM requiring pharmacotherapy reported high levels of decision comfort and satisfaction with both metformin and insulin, although they expressed different priorities in medication decision-making. These results can inform future patient-centered GDM treatment strategies.

KEY POINTS

· Pregnant individuals with GDM requiring pharmacotherapy expressed a high level of decisional comfort and satisfaction with medication decision making.. · Individuals placed different priorities on deciding to take metformin versus insulin.. · These results can inform interventions aimed at delivering person-centered diabetes care in pregnancy that integrates patient autonomy and knowledge about treatment options..