Leucine kinetics during a brief fast in diabetes in pregnancy

Diet and Healthy Lifestyle in the Management of Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) among pregnant women increases the risk of both short-term and long-term complications, such as birth complications, babies large for gestational age (LGA), and type 2 diabetes in both mother and offspring. Lifestyle changes are essential in the management of GDM. In this review, we seek to provide an overview of the lifestyle changes which can be recommended in the management of GDM. The diet recommended for women with GDM should contain sufficient macronutrients and micronutrients to support the growth of the foetus and, at the same time, limit postprandial glucose excursions and encourage appropriate maternal gestational weight gain. Blood glucose excursions and hyperglycaemic episodes depend on carbohydrate-intake. Therefore, nutritional counselling should focus on the type, amount, and distribution of carbohydrates in the diet. Further, physical activity has beneficial effects on glucose and insulin levels and it can contribute to a better glycaemic control.

Amino acids, glutamine, and protein metabolism in very low birth weight infants

Glutamine has been proposed to be conditionally essential for premature infants, and the currently used parenteral nutrient mixtures do not contain glutamine. De novo glutamine synthesis (DGln) is linked to inflow of carbon into and out of the tricarboxylic acid (TCA) cycle. We hypothesized that a higher supply of parenteral amino acids by increasing the influx of amino acid carbon into the TCA cycle will enhance the rate of DGln. Very low birth weight infants were randomized to receive parenteral amino acids either 1.5 g/kg/d for 20 h followed by 3.0 g/kg/d for 5 h (AA1.5) or 3.0 g/kg/d for 20 h followed by 1.5 g/kg/d for 5 h (AA3.0). A third group of babies received amino acids 1.5 g/kg/d for 20 h followed by 3.0 g/kg/d for 20 h (AA-Ext). Glutamine and protein/nitrogen kinetics were examined using [5-(15)N]glutamine, [2H5]phenylalanine, [1-(13)C,15N]leucine, and [15N2]urea tracers. An acute increase in parenteral amino acid infusion for 5 h (AA1.5) resulted in decrease in rate of appearance (Ra) of phenylalanine and urea, but had no effect on glutamine Ra. Infusion of amino acids at 3.0 g/kg/d for 20 h resulted in increase in DGln, leucine transamination, and urea synthesis, but had no effect on Ra phenylalanine (AA-Ext). These data show an acute increase in parenteral amino acid-suppressed proteolysis, however, such an effect was not seen when amino acids were infused for 20 h and resulted in an increase in glutamine synthesis.

Rationale for prevention and treatment of glucose-mediated macrosomia: a protocol for gestational diabetes

OBJECTIVE

To formulate a rationale for preventing and treating hyperglycemia during pregnancy and the concomitant risk of macrosomia.

METHODS

We reviewed pertinent studies in the literature and personal experience with patients who had gestational diabetes. In addition, dietary and exercise interventions in the management of such patients were assessed.

RESULTS

During pregnancy, sequential hormonal increases occur to provide glucose substrate to the fetus. When a pregnant woman has a limited insulin secretory capacity and cannot produce enough insulin to compensate for the effect of diabetogenic hormones, gestational diabetes occurs (usually during the second trimester). Maternal hyperglycemia reportedly increases fetal secretion of insulin, and fetal hyperinsulinemia may predispose the fetus to macrosomia. Thus, metabolic abnormalities associated with diabetes during pregnancy result in long-term effects on the offspring, including insulin resistance, obesity, and diabetes, which in turn may contribute to transmission of risk for development of the same problems in subsequent generations. Insulin therapy, dietary measures, and exercise have helped to achieve euglycemia in patients with gestational diabetes.

CONCLUSION

Universal screening for gestational diabetes is optimally performed at 26 weeks of gestation. Treatment of diagnosed cases, by insulin, diet, and exercise regimens, will decrease the occurrence of glucose-related macrosomia, improve the outcome of the pregnancy, and reduce the risks for obesity, hypertension, and diabetes in future progeny.

Nutritional intake and placental size in gestational diabetic pregnancies--a preliminary observation

A disproportionately large placenta may represent an adaptive response to adverse intrauterine conditions. Both maternal nutritional intake and presence of gestational diabetes (GDM) have been found to affect relative placental growth. As dietary modification is part of the standard management in GDM women, the observed increase in placental size in these women may be partly due to dietary modification. In this study, we set out to examine the relationship between dietary intake and placental size in GDM pregnancies. Food diaries for five consecutive days for 52 women diagnosed with GDM were obtained to assess their nutritional intake in terms of total calories, carbohydrate, protein and fat. Spearman's correlations were calculated for nutritional intake and various factors that may correlate with placental weight. There was a significant inverse relationship (P=0.021) between placental weight and protein intake. No correlations with the other two nutritional components could be demonstrated. Maternal nutritional intake was not correlated with infant birthweight. It is possible that dietary modulations improve GDM pregnancy outcome, not only by improving glycaemic controls but also by affecting placental growth by altering the proportion of protein intake.

Serine metabolism in human pregnancy

Serine plays an important role in intermediary metabolism as a source of one carbon pool for nucleotide biosynthesis, as a precursor for glycine and glucose, and as a contributor to cysteine biosynthesis. A unique serine-glycine cycling between the liver and the placenta has been demonstrated in the sheep fetus. We hypothesized that, because of serine's role in growth and development, significant changes in serine metabolism will occur in pregnancy with advancing gestation. The rate of appearance (R(a)) of serine and its metabolism were quantified in healthy women longitudinally through pregnancy with a [2-(15)N(13)C]serine tracer. The contribution of serine N to urea and the rate of oxidation of serine were measured using the precursor-product relation. Plasma serine concentrations and serine R(a) were lower in pregnant (P) women, in both early and late gestation, compared with nonpregnant (NP) women [plasma serine: NP, 113 +/- 24.5; P early, 71.9 +/- 6.2; P late, 68.5 +/- 9.6 micromol/l; serine R(a): NP (n = 7), 152.9 +/- 42.8; P early (n = 12), 123.7 +/- 21.5; P late (n = 8), 102.8 +/- 18.2 micromol x kg(-1) x h(-1)]. Serine contributed approximately 6% to urea N and 15-20% to the plasma glycine pool, and oxidation of serine represented approximately 8% of R(a). There was no significant difference between P and NP subjects. Glucose infusion, at 3 mg x kg(-1) x min(-1) in P subjects, resulted in a decrease in serine R(a) and an increase in oxidation. The decrease in serine turnover in pregnancy may represent a decrease in alpha-amino nitrogen turnover related to a decreased rate of branched-chain amino acid transamination and caused by pregnancy-related hormones aimed at nitrogen conservation and accretion.

Whole body protein kinetics in women: effect of pregnancy and IDDM during anabolic stimulation

The effects of pregnancy and type 1 diabetes [insulin-dependent diabetes mellitus (IDDM)] on protein metabolism are still uncertain. Therefore, six normal and five IDDM women were studied during and after pregnancy, using [(13)C]leucine and [(2)H(5)]phenylalanine with a hyperinsulinemic-euglycemic clamp and amino acid infusion. Fasting total plasma amino acids were lower in pregnancy in normal but not IDDM women (2,631 +/- 427 vs. 2,057 +/- 471 and 2,523 +/- 430 vs. 2,500 +/- 440 micromol/l, respectively). Whole body protein breakdown (leucine) increased in pregnancy [change in normal (delta N) and IDDM women (delta D) 0.59 +/- 0.40 and 0.48 +/- 0.26 g. kg(-1). day(-1), both P < 0.001], whereas reductions in protein breakdown due to insulin/amino acids (delta N -0.57 +/- 0.19, delta D -0.58 +/- 0.20 g. kg(-1). day(-1), both P < 0.001) were unaffected by pregnancy. Protein breakdown in IDDM women was not higher than normal, and neither pregnancy nor type 1 diabetes altered the insulin sensitivity of amino acid turnover. Nonoxidized leucine disposal (protein synthesis) increased in pregnancy (delta N 0.67 +/- 0.45, delta D 0.64 +/- 0.34 g. kg(-1). day(-1), both P < 0.001). Pregnancy reduced the response of phenylalanine hydroxylation to insulin/amino acids in both groups (delta N -1.14 +/- 0.74, delta D -1. 12 +/- 0.77 g. kg(-1). day(-1), both P < 0.05). These alterations may enable amino acid conservation for protein synthesis and accretion in late pregnancy. Well-controlled type 1 diabetes caused no abnormalities in the regulation of basal or stimulated protein metabolism.

Inverse alterations of BCKA dehydrogenase activity in cardiac and skeletal muscles of diabetic rats

Rat cardiac and skeletal muscles, which have been used as model tissues for studies of regulation of branched-chain alpha-keto acid (BCKA) oxidation, vary greatly in the activity state of their BCKA dehydrogenase. In the present experiment, we have investigated whether they also vary in response of their BCKA dehydrogenase to a metabolic alteration such as diabetes and, if so, to investigate the mechanism that underlies the difference. Diabetes was produced by depriving streptozotocin-treated rats of insulin administration for 96 h. The investigation of BCKA dehydrogenase in the skeletal muscle (gastrocnemius) showed that diabetes 1) increased its activity, 2) increased the protein and gene expressions of all of its subunits (E(1)alpha, E(1)beta, E(2)), 3) increased its activity state, 4) decreased the rate of its inactivation, and 5) decreased the protein expression of its associated kinase (BCKAD kinase) without affecting its gene expression. In sharp contrast, the investigation of BCKA dehydrogenase in the cardiac muscle showed that diabetes 1) decreased its activity, 2) had no effect on either protein or gene expression of any of its subunits, 3) decreased its activity state, 4) increased its rate of inactivation, and 5) increased both the protein and gene expressions of its associated kinase. In conclusion, our data suggest that, in diabetes, the protein expression of BCKAD kinase is downregulated posttranscriptionally in the skeletal muscle, whereas it is upregulated pretranslationally in the cardiac muscle, causing inverse alterations of BCKA dehydrogenase activity in these muscles.

Evaluation of phenylalanine and tyrosine metabolism in late human pregnancy

The [2H5]-phenylalanine method for measurement of protein metabolism requires the phenylalanine hydroxylation to tyrosine to be calculated from the tyrosine flux. Although this can be estimated, for pregnancy, we made a direct measurement of the molar ratio of the fluxes of tyrosine and phenylalanine from protein breakdown (Pt/Pp) using [2H2]-tyrosine infusion. Six normal pregnant women were studied at 37 weeks' gestation. While fasting, they were administered a 3-hour primed-constant infusion with [13C]-leucine, [2H5]-phenylalanine, and [2H2]-tyrosine. Leucine (alpha-ketoisocaproic acid [KIC]) flux was 136.2+/-15.1 micromol/kg/h (mean +/- SD), phenylalanine flux 41.2+/-5.6, and tyrosine flux 25.0+/-6.0, and phenylalanine hydroxylation was 3.3+/-2.1 micromol/kg/h. The mean tyrosine to phenylalanine molar flux ratio (Pt/Pp) was 0.52+/-0.10, lower than the ratio of 0.65 to 0.85 reported in normal nonpregnant subjects and 0.73 estimated from animal studies. We studied protein metabolism in six additional pregnant women and six nonpregnant women using [13C]-leucine and [2H5]-phenylalanine infusions only and applied the lower Pt/Pp ratio to the former group. Tyrosine flux (42.0+/-7.2 micromol/kg/h) and phenylalanine hydroxylation (9.2+/-4.2 micromol/kg/h) were significantly higher in nonpregnant subjects than in both groups of pregnant subjects. The percent contribution of phenylalanine hydroxylation to total tyrosine flux was reduced from 20% to 14%. When using [2H5]-phenylalanine to study whole-body protein metabolism in pregnancy and tyrosine flux is not measured directly by infusion of [2H2]-tyrosine, the lower Pt/Pp ratio is required. The phenylalanine model shows that tyrosine flux derived from protein breakdown and phenylalanine hydroxylation are both reduced in pregnancy.

The new obstetrics: its integration into neonatal clinical practise, teaching and research

Most neonatologists have not yet incorporated into their teaching, clinical service and research the advances in high risk obstetrics particularly as it relates to fetal surveillance. This brief review emphasizes some of the "new obstetrics" from the viewpoint of perinatal medicine, particularly in terms of neonatal teaching and the design of future neonatal research. The information that can be obtained about an infant prenatally by the use of ultrasound. power doppler, computerized fetal heart rate monitoring, cordocentesis, etc is extensive and yet, has rarely been utilized in the design of neonatal research protocols. It is becoming imperative that the "new obstetrics" be recognized and utilized in modern neonatal thinking if a truly "perinatal medicine" is to be practised.

Oxidative metabolism in insulin-treated gestational diabetes mellitus

To investigate whether protein, carbohydrate, and fat metabolism was normalized in insulin-treated gestational diabetes mellitus (GDM), eight Hispanic women with GDM and eight healthy controls were studied at 32-36 wk of gestation and 6 wk postpartum. Net substrate utilization was measured using room respiration calorimetry. Exogenous substrate oxidation was determined by 13C recovered in breath CO2 from 13C-labeled leucine, glucose, and Hiolein. Women with GDM had higher 24-h oxygen consumption, carbon dioxide production, total energy expenditure, and basal metabolic rates than controls due to larger body mass. Adjusted for weight or fat-free mass, total energy expenditure, basal metabolic rate, and basal and 24-h whole body net protein, carbohydrate, and fat utilization did not differ between insulin-treated GDM subjects and controls in pregnancy or postpartum. Oxidation of [13C]leucine and [13C]glucose did not differ by group or pregnancy status. Recovery of exogenously administered [13C]Hiolein, a biosynthetic triglyceride, as breath 13CO2 was significantly lower in the GDM group antepartum and postpartum (P = 0.02), indicating lower oxidation of exogenous triglycerides in GDM.

Exercise and the nutritional management of diabetes during pregnancy

Although exercise is widely accepted as an important component in programs of maintaining a healthy lifestyle, the question of safety and utility of an exercise program for pregnant diabetic women is still controversial. Pregnant women who have diabetes want some direction as to what their possibilities are regarding exercise programs, as there is accumulating evidence that exercise during pregnancy has some advantages for them. In addition, there is now a consensus of thought that the ideal nutritional therapy for the gestational diabetic woman is a diet that facilitates normoglycemia. This article outlines a program that not only improves metabolic control through dietary principles and exercise prescriptions to achieve and maintain normoglycemia, but also will be safe for the mother and her baby, is enjoyable, and also has physical benefits for the mother.