Gestational diabetes mellitus and obesity

Prevalence and Trends in Gestational Diabetes Mellitus Among Women in the United States, 2006-2017: A Population-Based Study

The prevalence of gestational diabetes mellitus (GDM) has increased with the increasing rate of obesity. However, national data on the prevalence and secular trends of GDM during the past decade in the United States are lacking. This study included 37,357 women aged more than 18 years and who had ever been pregnant from the National Health Interview Survey (NHIS). We examined GDM prevalence in 2006, 2016, and 2017, with age-standardized to the US population in 2000. We found that the prevalence of GDM per 100 people increased from 4.6 (95% CI, 4.1-5.1) in 2006 to 8.2 (95% CI, 7.5-8.9) in 2016 (test for difference; P <0.001), with a relatively increased rate of 78%. Non-Hispanic white women tended to have a lower increase (2.8%) than non-Hispanic black women (3.8%), Hispanic women (4.1%), and women of other race/ethnicity (8.4%). The prevalence of GDM in non-Hispanic white women was higher than that in non-Hispanic black women in 2006 (4.8% vs 3.5%, P = 0.006); such differences became non-significant in 2016 (P = 0.72). Additionally, the increase of GDM from 2006 to 2016 tended to be more evident among women who were overweight (25≤ BMI ≤30 kg/m²), physically inactive, and with family income below the poverty threshold than women in other BMI ranges, with more physical activity, and with higher incomes. The prevalence of GDM per 100 people in 2017 was 8.4 (7.6-9.2), and there was no significant change in the overall and subgroup prevalence compared with 2016. Collectively, in the United States, the prevalence of GDM continuously increased, nearly doubled, from 2006 to 2016, and then leveled off in 2017. The increase appeared more marked among the minority populations and subpopulations with overweight people, insufficient activity, and family incomes below the poverty threshold.

Diet and Nutritional Interventions with the Special Role of Myo-Inositol in Gestational Diabetes Mellitus Management. An Evidence-Based Critical Appraisal

BACKGROUND

Gestational Diabetes Mellitus (GDM), defined as glucose intolerance with onset or first recognition during pregnancy, represents one of the most common maternal-fetal complications during pregnancy and it is associated with poor perinatal outcomes. To date, GDM is a rising condition over the last decades coinciding with the ongoing epidemic of obesity and Type 2 Diabetes Mellitus (T2DM).

OBJECTIVE

The aim of this review is to discuss the role of diet and nutritional interventions in preventing GDM with the explanation of the special role of myo-inositol (MI) in this matter.

METHODS

We performed an overview of the most recent literature data on the subject with particular attention to the effectiveness of diet and nutritional interventions in the prevention of GDM with the special role of MI.

RESULTS

Nutritional intervention and physical activity before and during pregnancy are mandatory in women affected by GDM. Moreover, the availability of insulin-sensitizers such as different forms of inositol has dramatically changed the scenario, allowing the treatment of several metabolic diseases, such as those related to glucose dysbalance. Although the optimal dose, frequency, and form of MI administration need to be further investigated, diet supplementation with MI appears to be an attractive alternative for the GDM prevention as well as for the reduction of GDM-related complications.

CONCLUSIONS

More studies should be conducted to prove the most effective nutritional intervention in GDM. Regarding the potential effectiveness of MI, further evidence in multicenter, randomized controlled trials is needed to draw firm conclusions.

Phenotypic and genotypic differences between Indian and Scandinavian women with gestational diabetes mellitus

OBJECTIVE

Gestational diabetes mellitus (GDM) is a transient form of diabetes characterized by impaired insulin secretion and action during pregnancy. Population-based differences in prevalence exist which could be explained by phenotypic and genetic differences. The aim of this study was to examine these differences in pregnant women from Punjab, India and Scandinavia.

METHODS

Eighty-five GDM/T2D loci in European and/or Indian populations from previous studies were assessed for association with GDM based on Swedish GDM criteria in 4018 Punjabi Indian and 507 Swedish pregnant women. Selected loci were replicated in Scandinavian cohorts, Radiel (N = 398, Finnish) and STORK/STORK-G (N = 780, Norwegian).

RESULTS

Punjabi Indian women had higher GDM prevalence, lower insulin secretion and better insulin sensitivity than Swedish women. There were significant frequency differences of GDM/T2D risk alleles between both populations. rs7178572 at HMG20A, previously associated with GDM in South Indian and European women, was replicated in North Indian women. The T2D risk SNP rs11605924 in the CRY2 gene was associated with increased GDM risk in Scandinavian but decreased GDM risk in Punjabi Indian women. No other overlap was seen between GDM loci in both populations.

CONCLUSIONS

Gestational diabetes mellitus is more common in Indian than Swedish women, which partially can be attributed to differences in insulin secretion and action. There was marked heterogeneity in the GDM phenotypes between the populations which could only partially be explained by genetic differences.

Adipokines and Insulin Resistance According to Characteristics of Pregnant Women with Gestational Diabetes Mellitus

BACKGROUND

The aim of this study was to evaluate adipokines concentration and insulin resistance according to maternal age or obesity at pregnancy and weight change at diagnosed gestational diabetes mellitus (GDM) in pregnant women with GDM.

METHODS

This study included 57 pregnant women who were diagnosed with GDM at 24 to 28 weeks of gestation. The subjects were classified into two or three groups according to pre-pregnancy body mass index (BMI, <25 kg/m² vs. ≥25 kg/m²), maternal age at pregnancy (<35 years old vs. ≥35 years old), and weight change during pregnancy at screening for GDM (weight change below, within, and in excess of the recommended range). They were respectively compared in each group.

RESULTS

Leptin, homeostasis model assessment of insulin resistance (HOMA-IR), and HOMA2-%B were increased in the group with pre-pregnancy BMI ≥25 kg/m². Leptin and HOMA-IR were positively correlated with BMI both before pregnancy and at screening for GDM. There were no significant correlations between HOMA-IR and adipokines. HOMA-IR showed positive correlation with HOMA2-%B and negative correlation with HOMA2-%S.

CONCLUSION

Leptin and HOMA-IR at diagnosed GDM were increased in the GDM patients with obesity before pregnancy. They were positively correlated with BMI both before pregnancy and at screening for GDM. The effect of maternal age at pregnancy and weight change during pregnancy at GDM screening on adipokines and insulin resistance might be less pronounced than the effect of maternal obesity.

Diabetes prevention: Reproductive age women affected by insulin resistance

In the United States, 29.1 million people are affected by diabetes, of which 95% have type 2 diabetes. There has been a fivefold increase in type 2 diabetes in the latter half of the 20th century, an increase strongly linked to the obesity epidemic in the United States. In addition, insulin resistance affects 86 million Americans, or more than one-third of the adult population, as manifested by impaired fasting glucose tolerance with random glucose values ranging from ⩾100 to <126 mg/dL. In all, 90% of those affected by impaired fasting glucose tolerance or pre-diabetes are unaware of their metabolic derangement. Although impaired fasting glucose tolerance increases one's risk of developing type 2 diabetes, once identified, application of lifestyle changes by affected individuals may avoid or delay the onset of type 2 diabetes. For reproductive age women who are found to have impaired fasting glucose tolerance, lifestyle changes may be an effective tool to diminish the reproductive health consequences of insulin resistance related diseases.

Compliance with National Institute of Health and Care Excellence risk-based screening for Gestational Diabetes Mellitus in nulliparous women

OBJECTIVE

To investigate compliance with risk-based screening for Gestational Diabetes Mellitus (GDM) in a nulliparous cohort.

DESIGN

A retrospective analysis of nulliparous women recruited to a prospective cohort, the Screening for Pregnancy Endpoints (SCOPE) study, was performed. Population included 2428 healthy nulliparous women with singleton pregnancies, recruited within Cork, Ireland; and Manchester, Leeds and London, United Kingdom. Compliance with risk factor screening for GDM was assessed in relation to the following risk factors: obesity, family history of diabetes and increased ethnic risk. GDM was diagnosed using an oral Glucose Tolerance Test (GTT) with locally employed diagnostic criteria. Statistical analysis was performed using Statistical Packages for Social Sciences (SPSS V22). Descriptive statistics are presented for the various baseline characteristics using numbers and percentages. Cross tabulation was used to compare relevant groups. When comparing group distributions Chi-square test was used. p-value <0.05 was considered statistically significant.

RESULTS

In the entire cohort of 2432 women, 27% (650 Women) had one or more identifiable risk factors as defined by National Institute of Health and Care Excellence (NICE) for GDM. Of those that had identifiable GDM risk factors according to the NICE guidelines, 395(60.8%) were appropriately screened. 253 (38.9%) had risk factors but were not screened. 261 (14.6%) had no GDM NICE risk factors but were screened with an oral GTT. Women with a risk factor that were screened with a GTT had an 8.9% (n=34) prevalence of GDM. Of those that were screened but did not have a risk factor 7.7% (n=20) were diagnosed with GDM. Overall, 2% (54 women) of the cohort had a diagnosis of GDM. Ethnicity was the risk factor most likely to be missed (n=55, 66.3%). The GTT test was completed within the recommended gestational window (24-28 weeks) 56.6% (n=371) of the time.

CONCLUSION

This study highlights poor compliance with risk factor screening for GDM in nulliparous women. Further investigation into the underlying reasons is warranted as well as the implications for pregnancy outcome.

TRIAL REGISTRATION NUMBER

ACTRN12607000551493.

Gestational diabetes mellitus treatment reduces obesity-induced adverse pregnancy and neonatal outcomes: the St. Carlos gestational study

BACKGROUND

Obesity and gestational diabetes mellitus (GDM) increase the morbidity of the mother and newborn, which could increase further should they coexist. We aimed to determine the risk of adverse pregnancy and neonatal outcomes associated with excess weight (EW), and within this group identify potential differences between those with and without GDM.

METHODS

We carried out a post-hoc analysis of the St. Carlos Gestational Study which included 3312 pregnant women, arranged in 3 groups: normal-weight women (NWw) (2398/72.4%), overweight women (OWw) (649/19.6%) and obese women (OBw) (265/8%). OWw and OBw were grouped as EW women (EWw). We analyzed variables related to adverse pregnancy and neonatal outcomes.

RESULTS

The relative risk (95% CI) for GDM was 1.82 (1.47 to 2.25; p<0.0001) for OWw, and 3.26 (2.45 to 4.35; p<0.0001) in OBw. Univariate analysis showed associations of EW to higher rates of prematurity, birth weight >90th centile, newborns admitted to neonatal intensive care unit (NICU), instrumental delivery and cesarean delivery (all p<0.005). Multivariate analysis, adjusted for parity and ethnicity, showed that EW increased the risk of prematurity, admission to NICU, cesarean and instrumental delivery, especially in EWw without GDM. NWw with GDM had a significantly lower risk of admission to NICU and cesarean delivery, compared with NWw without GDM.

CONCLUSIONS

EW is detrimental for pregnancy and neonatal outcomes, and treatment of GDM contributes to lowering the risk in EWw and NWw. Applying the same lifestyle changes to all pregnant women, independent of their weight or GDM condition, could improve these outcomes.

Comparison of the effects of gestational weight gain on pregnancy outcomes between non-diabetic and diabetic women

OBJECTIVE

Appropriate gestational weight gain (GWG) is important in diabetic women. Current GWG guideline is for US general population, but not specific for diabetic women. We compared the effect of GWG on perinatal outcomes between diabetic and non-diabetic women.

METHODS

Fifty two hundred and twelve women who delivered live singleton infants at Korea University Medical Center from January 2009 to December 2013 were included. One hundred twenty-nine overt diabetes women and 322 gestational diabetes women were categorized as diabetic women, and the others were categorized as none-diabetic women. 5,212 women were categorized by GWG (low 1,081; adequate 2,102; or high 2,029; according to the 2009 Institute of Medicine guidelines), and each of the 3 GWG groups was categorized into 2 groups; diabetic or non-diabetic women. And then, we compared perinatal outcomes between diabetic and non-diabetic groups.

RESULTS

In each 3 GWG groups, primary cesarean section delivery, high birth weight, and large for gestational age rates were significantly higher in diabetic women than non-diabetic women. Only in adequate GWG group, preterm birth rate was significantly higher in diabetic women than non-diabetic women.

CONCLUSION

Our study shows that diabetic women had higher rates of adverse perinatal outcomes than non-diabetic women, although they achieved same GWG. It suggests that current GWG guideline may not be adequate for diabetic women, and that diabetic women may need more strict GWG control than normal population.

Maternal glucose level and body mass index measured at gestational diabetes mellitus screening and the risk of macrosomia: results from a perinatal cohort study

OBJECTIVE

To examine the impact of maternal blood glucose (BG) level and body mass index (BMI) measured at gestational diabetes mellitus (GDM) screening on the risk of macrosomia.

DESIGN

A perinatal cohort of women were followed up from receiving perinatal healthcare to giving birth.

SETTING

Beichen District, Tianjin, China between June 2011 and October 2012.

PARTICIPANTS

1951 women aged 19-42 years with valid values of BMI and BG level at GDM screening (24-28 weeks gestation), singleton birth and birth weight (BW)>2500 g.

MAIN OUTCOMES AND MEASURES

Primary outcome was macrosomia (BW>4000 g). BG level and BMI were measured at GDM screening.

RESULTS

191 (9.7%) newborns were macrosomia. The ORs (95% CIs) of macrosomia from multiple logistic regression were 1.14 (1.10 to 1.19, p<0.0001) for BMI and 1.11 (1.01 to 1.23, p=0.03) for BG. When BMI and BG levels (continuous) were modelled simultaneously, the OR for BMI was similar, but significantly attenuated for BG. Areas of receiver operating characteristics (ROC) were 0.6530 (0.6258 to 0.6803) for BMI and 0.5548 (0.5248 to 0.5848) for BG (χ(2)=26.17, p<0.0001). BG (mmol/L, <6.7, 6.7-7.8 or ≥7.8) and BMI in quintiles (Q1-Q5) were evaluated with BG <6.7 and Q2 BMI as the reference group. The ORs of macrosomia were not statistically different for mothers in Q1 or Q2 of BMI regardless of the BG levels; the ORs for ≥Q3 of BMI were elevated significantly with the highest OR observed in Q5 of BMI and BG levels ≥7.8 (6.93 (2.61 to 18.43), p<0.0001).

CONCLUSIONS

High BMI measured at GDM screening was the most important determinant for risk of macrosomia. These findings suggest that GDM screening may be a critical gestational time point to initiate maternal weight control oriented intervention strategy to lower the risk.

Health-related behaviors in women with lifestyle-related diseases

Lifestyle related diseases associated with physical inactivity and poor diet quality, represent a major health burden. This study assessed negative and positive health habits and health care utilization in healthy women (n = 50) and women with lifestyle related diseases such as polycystic ovary syndrome (PCOS) (n = 50), gestational diabetes mellitus (GDM) (n = 44) and type 2 diabetes (DM2) (n = 43). A significant difference existed across groups for negative health habits (P = .012) with a trend for positive health habits (P = .06) elevated in women with PCOS. Women with DM2 had the highest amount of health care utilization including doctors office visits (P < .001), overnight hospital treatments (P < .001) and emergency room treatments (P = .01). Health practitioners would benefit from both encouraging positive health habits and addressing negative health habits. Furthermore, self-management and emphasizing the pivotal role patients' have in managing their illness is important for optimizing health outcomes. Elevated health care utilization rates were observed in women with DM2 but there were no differences in positive health habits across sub-groups. Encouraging lifestyle modification in women with precursor diseases such as GDM and PCOS is vital in order to prevent progression to DM2.

The prognostic value of a normal oral glucose tolerance test in pregnant women who tested positive at screening: a validation study

BACKGROUND

Controversies surround a diagnosis of gestational diabetes mellitus (GDM). The objective of this study was to evaluate the oral glucose tolerance test (OGTT) for the prediction of adverse gestational and perinatal outcomes in pregnant women with a positive screening test for diabetes mellitus and a negative diagnosis, i.e. a normal 3-hour OGTT.

METHODS

This validation study evaluated 409 pregnant women who tested positive for diabetes mellitus at screening. Perinatal and maternal outcomes were considered. Sensitivity and specificity were calculated for each of the values of the OGTT as a diagnostic test, with the gold standard being perinatal outcome.

RESULTS

The most frequent risk factors were obesity, arterial hypertension and advanced maternal age. The most common neonatal outcomes were large-for-gestational-age infants, Cesarean delivery and preterm birth. A fasting blood glucose level of 87 mg/dL was the most powerful predictor of adverse perinatal outcome.

CONCLUSIONS

At the cut-off level adopted by the American Diabetes Association, gestational OGTT was able to successfully identify in which pregnant women outcome would be unfavorable.

The pharmacological treatment of obesity: Past, present and future

Currently, obesity presents one of the biggest health problems. Management strategies for weight reduction in obese individuals include changes in life style such as exercise and diet, behavioral therapy, and pharmacological treatment, and in certain cases surgical intervention. Diet and exercise are best for both prevention and treatment, but both require much discipline and are difficult to maintain. Drug treatment of obesity offer a possible adjunct, but it may only have modest results, limited by side effects; furthermore, the weight lowering effects last only as long as the drug is being taken and, unfortunately, as soon as the administration is stopped, the weight is regained. These strategies should be used in a combination for higher efficacy. Drugs used to induce weight loss have various effects: they increase satiety, reduce the absorption of nutrients or make metabolism faster; but their effect is usually moderate. In the past, several drugs were used in the pharmacological therapy of weight reduction including thyroid hormone, dinitrophenol, amphetamines and their analogues, e.g. fenfluramine, At present, only orlistat is available in the long term treatment (≥24 weeks) of obesity as sibutramine and rimonabant were withdrawn form the market. Several new anti-obesity drugs are being tested at present, and liraglutide, a GLP-1 analogue (incretin mimetic), is the most promising one. Orv. Hetil., 2012, 153, 363–373.

The obese woman with gestational diabetes: effects of body mass index and weight gain in pregnancy on obstetric and glycaemic outcomes

BACKGROUND

Obese women with gestational diabetes mellitus (GDM) represent a high-risk group in pregnancy, although the effects of increasing degrees of obesity and weight gain in pregnancy in this group is poorly defined.

METHODS

We performed a retrospective analysis of 375 singleton pregnancies complicated by maternal obesity and GDM. Women with a body mass index (BMI) of 30-35 kg/m(2) were compared with those with a BMI of ≥ 35 kg/m(2). Additionally, women were categorized according to weight gain in pregnancy: Group A (<0.18 kg/week), Group B (0.18-0.27 kg/week), Group C (>0.27 kg/week).

RESULTS

Obstetric outcomes did not differ between the groups; however, postpartum dysglycaemia was more likely in women with a BMI ≥ 35 kg/m(2) (odds ratio [OR] 3.2, 95% confidence interval [CI]: 1.2-8.9). Group B and Group C had higher odds of LGA (OR 3.8, 95% CI: 1.3-11.3; OR 5.0, 95% CI: 2.0-12.1, respectively) compared with Group A. Group C also had a lower risk of SGA (OR 0.4, 95% CI: 0.2-1.0) and a higher risk of postpartum dysglycaemia (OR 6.8, 95% CI: 1.7-26.9) compared with Group A.

CONCLUSION

Greater degrees of obesity are associated with higher risk of abnormal metabolic outcomes after pregnancy. Excessive weight gain in pregnancy in obese women increases adverse obstetric and glycaemic outcomes. Our findings suggest that targets for weight gain in pregnancy for obese women should be reduced from current recommendations.

Present and future: pharmacologic treatment of obesity

Obesity now presents one of the biggest health problems of our times. Diet and exercise are best for both prevention and treatment; unfortunately, both require much discipline and are difficult to maintain. Medications offer a possible adjunct, but their effect is modest, they are limited by side effects, and the weight loss lasts only as long as the drug is being taken, since as soon as treatment is stopped, the weight is regained. Sibutramine, a sympathomimetic medication which was available for long-term treatment, is the most recent of the drugs to be withdrawn from the market due to side effects; in this case it was an increased risk of cardiovascular events. This paper reviews those medications which are available for treatment of obesity, including many of those recently taken off the market. It also discusses some of the newer treatments that are currently being investigated.

Promoting breastfeeding among obese women and women with gestational diabetes mellitus

Breastfeeding has many health benefits for women and their babies, but particularly if the woman is obese and/or had a pregnancy affected with gestational diabetes mellitus (GDM). Women who have had GDM are at high risk for developing metabolic syndrome or type 2 diabetes, and their offspring are at greater risk for these metabolic disorders both in childhood and later in adulthood. There is considerable evidence that breastfeeding may attenuate these risks. The aim of this article is to present the most recent evidence on what is known about how breastfeeding can mitigate the adverse metabolic effects of obesity and GDM on both mother and child, and describe best practices that can support and sustain breastfeeding, particularly in racial/ethnic communities at risk.