Prevalence of diabetes mellitus in pregnancy among Yup'ik Eskimos, 1987-1988

Prevalence of gestational diabetes in the United States and Canada: a systematic review and meta-analysis

BACKGROUND

An understanding of the prevalence of gestational diabetes mellitus among pregnant women is essential at local, national and international level so that appropriate health care interventions can be planned, financed and delivered.

METHODS

A systematic review and meta-analysis of primary research reporting the prevalence of gestational diabetes mellitus in Canada or the United States were carried out according to Meta-analysis of Observational Studies in Epidemiology guidelines. Four electronic databases were systematically searched in June 2023 to identify articles that reported gestational diabetes mellitus prevalence using universal screening in pregnant women from eligible general population samples. Estimates were combined using a random effects model, and the effects of moderator variables analysed.

RESULTS

There were 36 separate samples of women or deliveries (total sample size 1,550,917). Overall mean prevalence of gestational diabetes mellitus was 6.9% (95% CI: 5.7-8.3); 13.7% (95% CI: 10.7-17.3) in studies using a one-step screening strategy, and 5.2% (95% CI: 4.4-6.1) in those using a two-step strategy. Heterogeneity in technical methods between studies produced differences in estimates, as did different diagnostic thresholds used.

CONCLUSIONS

The meta-analysis suggests a slightly higher prevalence of gestational diabetes mellitus in Canada and the United States, compared to Europe, but highlights the need for standardised protocols for estimating gestational diabetes mellitus prevalence.

The impact of diagnostic criteria for gestational diabetes on its prevalence: a systematic review and meta-analysis

BACKGROUND

The absence of universal gold standards for screening of gestational diabetes (GDM) has led to heterogeneity in the identification of GDM, thereby impacting the accurate estimation of the prevalence of GDM. We aimed to evaluate the effect of different diagnostic criteria for GDM on its prevalence among general populations of pregnant women worldwide, and also to investigate the prevalence of GDM based on various geographic regions.

METHODS

A comprehensive literature search was performed in PubMed, Scopus and Google-scholar databases for retrieving articles in English investigating the prevalence of GDM. All populations were classified to seven groups based-on their diagnostic criteria for GDM. Heterogeneous and non-heterogeneous results were analyzed using the fixed effect and random-effects inverse variance model for calculating the pooled effect. Publication bias was assessed by Begg's test. The Meta-prop method was used for the pooled estimation of the prevalence of GDM. Meta-regression was conducted to explore the association between prevalence of GDM and its diagnostic criteria. Modified Newcastle-Ottawa Quality Assessment Scale for nonrandomized studies was used for quality assessment of the studies included; the ROBINS and the Cochrane Collaboration's risk of bias assessment tools were used to evaluate the risk of bias.

RESULTS

We used data from 51 population-based studies, i.e. a study population of 5,349,476 pregnant women. Worldwide, the pooled overall-prevalence of GDM, regardless of type of screening threshold categories was 4.4%, (95% CI 4.3-4.4%). The pooled overall prevalence of GDM in the diagnostic threshold used in IADPSG criteria was 10.6% (95% CI 10.5-10.6%), which was the highest pooled prevalence of GDM among studies included. Meta-regression showed that the prevalence of GDM among studies that used the IADPSG criteria was significantly higher (6-11 fold) than other subgroups. The highest and lowest prevalence of GDM, regardless of screening criteria were reported in East-Asia and Australia (Pooled-P = 11.4%, 95% CI 11.1-11.7%) and (Pooled-P = 3.6%, 95% CI 3.6-3.7%), respectively.

CONCLUSION

Over the past quarter century, the diagnosis of gestational diabetes has been changed several times; along with worldwide increasing trend of obesity and diabetes, reducing the threshold of GDM is associated with a significant increase in the incidence of GDM. The harm and benefit of reducing the threshold of diagnostic criteria on pregnancy outcomes, women's psychological aspects, and health costs should be evaluated precisely.

Diabetes care in the dispersed population of Greenland. A new model based on continued monitoring, analysis and adjustment of initiatives taken

Diabetes used to be a rare condition among Inuit in Greenland. However, research in recent decades has shown a high prevalence of undiagnosed diabetes. Addressing diabetes in the geographically dispersed population of Greenland presents a challenge to the health care system. In 2008, a new model of diabetes care was introduced in Greenland that included continual monitoring, analysis, and adjustment of initiatives taken. The overall aim of this review was to review the feasibility of the monitoring of an ongoing national diabetes care programme. After ten years of observation it was clear that monitoring of such a programme based on information in electronic medical records in Greenland was feasible. It was found that the majority of the population in Greenland was in contact with the health care system. Increased diagnostic activity resulted in an increased prevalence of diagnosed diabetes. The quality of diabetes care in Greenland and the testing effectiveness of gestational diabetes were improved. Microvascular complications were frequently observed among Greenlandic diabetic patients, except for retinopathy that was as an exception. In summary, this model may improve diabetes care and potentially care for other chronic conditions in Greenland, and may also be helpful in other remote settings where chronic disease care is difficult.Abbreviations: AD: Anno Domini; ADA: American Diabetes Association; BC: Before Christ; BMI: Body Mass Index; BP: Blood Pressure; CWB: Capillary Whole Blood; EMR: Electronic Medical Record; EASD: European Association for Study of Diabetes; GA: Gestational Age; GDM: Gestational Diabetes Mellitus; FIGO: The International Federation of Gynaecology and Obstetrics; HbA1c: Glycosylated haemoglobin; IDF: International Diabetes Federation; LDL: Low density lipoprotein; NDQIA: National Diabetes Quality Improvement Alliancel; NICE: National Institute for Health and Care Excellence; OECD: Organisation for Economic Co-operation and Development; OGTT: Oral Glucose Tolerance Test; QIH: Queen Ingrid Hospital; RCT: Randomised Controlled Tria;l T1D: Type 1 Diabetes; T2D: Type 2 Diabetes; UACR: Urine Albumin Creatinine Ratio; WHO: World Health Organisation.

Pancreatic carcinoma underlying a complex presentation in late pregnancy: a case report

BACKGROUND

Gestational diabetes mellitus is strongly related to the risk of pancreatic cancer in pregnant women, but gestational diabetes can precede a diagnosis of pancreatic cancer by many years. Women with a history of gestational diabetes showed a relative risk of pancreatic cancer of 7.1. Pancreatic adenocarcinoma is one of the most common malignancies associated with thromboembolic events. A clinical study showed that thromboembolic events were detected in 36% of patients diagnosed as having pancreatic cancer. Studies showed that gestational diabetes mellitus could be one of the important risk factors for pancreatic cancer.

CASE PRESENTATION

Gestational diabetes mellitus is associated with increased risk of breast and pancreatic cancer. This case report describes a 29-year-old Chinese woman who presented with: gestational diabetes mellitus; International Society on Thrombosis and Haemostasis criteria suggested disseminated intravascular coagulation with a score of 5; hemolysis, elevated liver enzymes, low platelet count syndrome; and pulmonary hypertension. After an intravenous injection of fibrinogen, she gave birth to a normal baby and following delivery, her blood pressure reached 180/110 mmHg. Laboratory analysis results showed elevated lactic dehydrogenase, decreased platelets and fibrinogen, and urine protein was positive. She was transfused with fresh frozen plasma, blood coagulation factor, and fibrinogen. Subsequently, she was transferred to a maternity intensive care unit, where magnesium sulfate seizure prophylaxis was continued for 24 hours to keep her magnesium level at a low therapeutic range. However, continuous oxygen therapy was needed to maintain her oxygenation. Further laboratory investigations revealed elevated carcinoembryonic antigen, carbohydrate antigen 19-9, and carbohydrate antigen 72-4. Positron emission tomography-computed tomography showed malignant carcinoma in the head of her pancreas with lymph node involvement along with bone, peritoneal, and left adrenal metastasis, as well as double lung lymphangitic carcinomatosis.

CONCLUSION

A differential diagnosis of digestive system neoplasm should be considered when a pregnant patient presents with gestational diabetes mellitus and disseminated intravascular coagulation, where the disseminated intravascular coagulation has no specific cause and cannot be readily resolved.

Obesity, Diabetes, and Birth Outcomes Among American Indians and Alaska Natives

Objectives To examine the relationships between prepregnancy diabetes mellitus (DM), gestational diabetes mellitus (GDM), and prepregnancy body mass index, with several adverse birth outcomes: preterm delivery (PTB), low birthweight (LBW), and macrosomia, comparing American Indians and Alaska Natives (AI/AN) with other race/ethnic groups. Methods The sample includes 5,193,386 singleton US first births from 2009-2013. Logistic regression is used to calculate adjusted odds ratios controlling for calendar year, maternal age, education, marital status, Kotelchuck prenatal care index, and child's sex. Results AI/AN have higher rates of diabetes than all other groups, and higher rates of overweight and obesity than whites or Hispanics. Neither overweight nor obesity predict PTB for AI/AN, in contrast to other groups, while diabetes predicts increased odds of PTB for all groups. Being overweight predicts reduced odds of LBW for all groups, but obesity is not predictive of LBW for AI/AN. Diabetes status also does not predict LBW for AI/AN; for other groups, LBW is more likely for women with DM or GDM. Overweight, obesity, DM, and GDM all predict higher odds of macrosomia for all race/ethnic groups. Conclusions for Practice Controlling diabetes in pregnancy, as well as prepregnancy weight gain, may help decrease preterm birth and macrosomia among AI/AN.

Gestational diabetes mellitus in Greenland: a national study of prevalence and testing efficacy

BACKGROUND

Within the last 20 years, the prevalence of gestational diabetes mellitus (GDM) has been reported to be increasing worldwide in correlation with ethnic and geographic variations. The actual prevalence of GDM throughout all of Greenland remains unknown.

OBJECTIVE

The aim of this study was to estimate the prevalence of GDM among Greenlanders and non-Greenlanders living in Greenland and to estimate the efficacy of testing for GDM.

DESIGN

This study was performed as an observational, cross-sectional study including all women with permanent address in Greenland who had given birth to a singleton during 2014. The prevalence of GDM was calculated as the proportion of all pregnant women tested with a 75-g 2-h glucose tolerance test who had a 2-h capillary whole-blood glucose value of 8.5 mmol/l or above. Testing efficacy was calculated as the proportion of women who fulfilled the testing criteria who were actually tested in Greenland in 2014.

RESULTS

A total of 794 women (727 Greenlanders and 67 non-Greenlanders) were included in the study. The prevalence of GDM among tested women was 3.3% (confidence interval, CI: 0.9-5.6) among Greenlanders and 12.5% (CI: 0-25.7) among non-Greenlanders, corresponding, respectively, to 1.0% (CI: 0.3-1.3) and 4.5% (CI: 0-9.4) of all singleton pregnancies in Greenland in 2014. The overall testing efficacy was 69.0% among all eligible residents of Greenland and 85.1% among eligible residents in the capital city, Nuuk.

CONCLUSION

In conclusion, the prevalence of GDM seems quite low in Greenland. Although diagnostic testing activity has improved within the last 6 years, still around one-third of all pregnant women in all Greenland fulfilling the testing criteria were not tested. Universal testing for GDM may be needed to improve testing of GDM in Greenland.

A cohort study of trends in the prevalence of pregestational diabetes in pregnancy recorded in UK general practice between 1995 and 2012

OBJECTIVE

To describe the characteristics of pregnant women with and without pregestational diabetes and to estimate the prevalence of pregestational diabetes in pregnant women recorded in a UK primary care database.

METHODS

The data source for this study is The Health Improvement Network (THIN) primary care database. Pregnant women with and without diabetes aged 16 years and over were identified using diagnostic Read codes and prescriptions for antidiabetics from medical records. Data were examined on: age, body mass index (BMI), social deprivation, smoking, ethnicity and glycaemic control. The prevalence of pregestational diabetes was calculated by diabetes type and calendar year between 1995 and 2012.

RESULTS

Data from 400,434 pregnancies suggests that women with pregestational diabetes were: older (median 29, 32 vs 29 years for type 1, type 2 and without diabetes, respectively), had higher BMI (median 25.0, 30.4 vs 23.9 k/m(2) for type 1, type 2 and without diabetes, respectively) and were registered with a general practice for longer than pregnant women without diabetes. The prevalence of type 1 diabetes in pregnancy increased from 1.56 to 4.09 per 1000 pregnancies between 1995 and 2015. For type 2 diabetes the increase was from 2.34 to 5.09 per 1000 pregnancies between 1995 and 2008 followed by a more rapid increase to 10.62 per 1000 pregnancies by 2012.

CONCLUSIONS

Pregnant women with pregestational diabetes were older, had higher BMI and were registered for longer than women without diabetes. The prevalence of type 1 and type 2 diabetes increased in pregnancy. The prevalence of type 2 diabetes rose more rapidly with a marked increase after 2008.

Solving the mystery: the true prevalence of gestational diabetes in indigenous women

This commentary briefly reviews what is currently known about estimating the prevalence of gestational diabetes in indigenous women. It offers insights into numerous factors likely playing a role in its observed variability. It also highlights important key concepts to consider in the overall evaluation and management of gestational diabetes in this particular population.

Evaluation of home testing to improve follow up after gestational diabetes (Fingerstick Assessments of Sugar Two-months postpartum or FAST)

OBJECTIVE

Historically the rates of postpartum glucose tolerance testing for women with gestational diabetes (GDM) average a suboptimal 33%. Barriers include the need for new mothers to miss work and/or arrange for childcare in order to engage in a two-hour test at a commercial lab. This pilot study was initiated to test the theory that a home testing regimen would be accepted by patients and increase the rate of postpartum glucose assessments relative to published rates, without requiring additional health-care staff or resources to achieve this goal.

STUDY DESIGN

Six weeks postpartum, women with GDM from an academic private practice were asked to check fingerstick blood glucose (FAST Protocol) four times a day for two days, and then obtain an oral glucose tolerance test (OGTT). The physician consultants saw the women each month during pregnancy and arranged the postpartum testing.

RESULTS

Two of 69 refused to be consented. Twelve of the remaining 67(18%) women completed both the FAST regimen and the OGTT, three completed only the OGTT and five completed only the FAST regimen for a final follow-up rate of 20/67 (30%). The demands of caring for a newborn, or the annoyance of fingersticks, were barriers to compliance.

CONCLUSIONS

In spite of intense physician involvement, this home testing regimen was not associated with an increase in the rates of women participating in postpartum glucose assessments.

Diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand and the United States

Recently proposed international guidelines for screening for gestational diabetes mellitus (GDM) recommend additional screening in early pregnancy for sub-populations at a high risk of type 2 diabetes mellitus (T2DM), such as indigenous women. However, there are criteria that should be met to ensure the benefits outweigh the risks of population-based screening. This review examines the published evidence for early screening for indigenous women as related to these criteria. Any publications were included that referred to diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand and the United States (n = 145). The risk of bias was appraised. There is sufficient evidence describing the epidemiology of diabetes in pregnancy, demonstrating that it imposes a significant disease burden on indigenous women and their infants at birth and across the lifecourse (n = 120 studies). Women with pre-existing T2DM have a higher risk than women who develop GDM during pregnancy. However, there was insufficient evidence to address the remaining five criteria, including the following: understanding current screening practice and rates (n = 7); acceptability of GDM screening (n = 0); efficacy and cost of screening for GDM (n = 3); availability of effective treatment after diagnosis (n = 6); and effective systems for follow-up after pregnancy (n = 5). Given the impact of diabetes in pregnancy, particularly undiagnosed T2DM, GDM screening in early pregnancy offers potential benefits for indigenous women. However, researchers, policy makers and clinicians must work together with communities to develop effective strategies for implementation and minimizing the potential risks. Evidence of effective strategies for primary prevention, GDM treatment and follow-up after pregnancy are urgently needed.

The current state of Indigenous and Aboriginal women with diabetes in pregnancy: a systematic review

To undertake a systematic review of diabetes in pregnancy (DIP), determining prevalence and impact on maternal and child health outcomes for Indigenous and Aboriginal women.

METHOD

Electronic searches of MEDLINE, Embase, CINAHL, ERIC, DARE, CDSR, PsycINFO, Austhealth and HealthInfoNet were undertaken. Changes in diagnostic criteria for DIP and variability in methodology meant a qualitative synthesis of the data was undertaken.

RESULTS

From the 142 potential studies, 42 peer reviewed journal articles met the inclusion criteria. GDM prevalence in 65% of studies was greater for Indigenous and Aboriginal women than the comparison groups; Pacific Islander 8.1%, Canadian Aboriginal 11.5%, American Indian 7.9%, Australian Aboriginal 8.4% compared with 2-5% worldwide. Of studies reporting high birth weight (>4000 g) and DIP, 75% had a higher than expected prevalence, 86% had higher macrosomia prevalence and 63% had higher stillbirth rates. Studies with Alaskan, Australian Aboriginal and Pacific Islander women had GDM prevalence both greater and less than comparison groups.

CONCLUSION

Correcting the health disparity for Indigenous and Aboriginal women with DIP is a health priority. DIP prevalence is not the same for all Indigenous and Aboriginal women. Inconsistent study design without robust data is interfering with accurate prevalence of DIP. New international consensus guidelines provide opportunities for high quality studies of DIP for Indigenous and Aboriginal women.

Prevalence of gestational diabetes mellitus among women born in Greenland: measuring the effectiveness of the current screening procedure

OBJECTIVES

To estimate the prevalence of gestational diabetes mellitus (GDM) among Greenlanders and to evaluate the quality of the current screening procedure for gestational diabetes.

STUDY DESIGN

Observational retrospective study of consecutive birth-log data and medical records on pregnant women who had given birth in Nuuk during 2008.

METHODS

Information about maternal weight, weight gain in pregnancy, height, blood pressure, result of oral glucose tolerance test, family history of diabetes, smoking and alcohol habits, ethnicity, delivery and birth weight and length was collected for women who had given birth in Nuuk, Greenland, during 2008.

RESULTS

A total of 233 women born in Greenland who had given birth to a singleton in Nuuk 2008 were included in the study. Of those, 37% were defined as having a high risk for GDM and thus met the screening criteria for GDM used in Greenland. However, only 54% of those women were screened. The prevalence of gestational diabetes was calculated to be 4.3% among high-risk Greenlandic pregnant women (2/46) (95% CI 0-10.0%).

CONCLUSIONS

Despite a suboptimal screening rate, the prevalence of GDM among Greenlanders seems to be relatively low and Greenlanders may thus be less prone to develop GDM. However, diabetes mellitus is a relatively new disease in Greenland, and glucose intolerance in pregnancy is more likely to affect the next generation. The screening rate is suboptimal, and it is recommended that the screening procedure be optimized in order to find and treat all women with GDM. The number of screened women compared to the number of births occurring annually could be used as an indicator of screening efficacy. Diabetes prevention initiatives should be given high priority to avoid high rates of GDM in the future, as increasing prevalence of the disease is now seen worldwide, regardless of race.

Periodontal pathogens and gestational diabetes mellitus

In previous cross-sectional or case-control studies, clinical periodontal disease has been associated with gestational diabetes mellitus. To test the hypothesis that, in comparison with women who do not develop gestational diabetes mellitus, those who do develop it will have had a greater exposure to clinical and other periodontal parameters, we measured clinical, bacteriological (in plaque and cervico-vaginal samples), immunological, and inflammatory mediator parameters 7 weeks before the diagnosis of gestational diabetes mellitus in 265 predominantly Hispanic (83%) women in New York. Twenty-two cases of gestational diabetes mellitus emerged from the cohort (8.3%). When the cases were compared with healthy control individuals, higher pre-pregnancy body mass index (p=0.004), vaginal levels of Tannerella forsythia (p=0.01), serum C-reactive protein (p=0.01), and prior gestational diabetes mellitus (p=0.006) emerged as risk factors, even though the clinical periodontal disease failed to reach statistical significance (50% in those with gestational diabetes mellitus vs. 37.3% in the healthy group; p=0.38).

Gestational diabetes as a risk factor for pancreatic cancer: a prospective cohort study

BACKGROUND

Diabetes is known to be associated with cancer of the pancreas, though there is some debate as to whether it is a cause or a consequence of the disease. We investigated the incidence of pancreatic cancer in a cohort of 37926 Israeli women followed for 28-40 years for whom information on diabetes had been collected at the time they gave birth, in 1964-1976, in Jerusalem. There were 54 cases of pancreatic cancer ascertained from the Israel Cancer Registry during follow-up.

METHODS

We used Cox proportional hazards models to adjust for age at baseline and explore effects of other risk factors, including ethnic groups, preeclampsia, birth order and birth weight of offspring.

RESULTS

We observed no cases of pancreatic cancer in the women with insulin dependent diabetes; however, there were five cases in the women with gestational diabetes. The interval between the record of diabetes in pregnancy and the diagnosis of pancreatic cancer ranged from 14-35 years. Women with a history of gestational diabetes showed a relative risk of pancreatic cancer of 7.1 (95% confidence interval, 2.8-18.0).

CONCLUSION

We conclude that gestational diabetes is strongly related to the risk of cancer of the pancreas in women in this population, and that gestational diabetes can precede cancer diagnosis by many years.

Increasing prevalence of gestational diabetes mellitus (GDM) over time and by birth cohort: Kaiser Permanente of Colorado GDM Screening Program

OBJECTIVE

The prevalence of gestational diabetes mellitus (GDM) varies in direct proportion with the prevalence of type 2 diabetes in a given population or ethnic group. Given that the number of people with diabetes worldwide is expected to increase at record levels through 2030, we examined temporal trends in GDM among diverse ethnic groups.

RESEARCH DESIGN AND METHODS

Kaiser Permanente of Colorado (KPCO) has used a standard protocol to universally screen for GDM since 1994. This report is based on 36,403 KPCO singleton pregnancies occurring between 1994 and 2002 and examines trends in GDM prevalence among women with diverse ethnic backgrounds.

RESULTS

The prevalence of GDM among KPCO members doubled from 1994 to 2002 (2.1-4.1%, P < 0.001), with significant increases in all racial/ethnic groups. In logistic regression, year of diagnosis (odds ratio [OR] and 95% CI per 1 year = 1.12 [1.09-1.14]), mother's age (OR per 5 years = 1.7 [1.6-1.8]) and ethnicity other than non-Hispanic white (OR = 2.1 [1.9-2.4]) were all significantly associated with GDM. Birth year remained significant (OR = 1.06, P = 0.006), even after adjusting for prior GDM history.

CONCLUSIONS

This study shows that the prevalence of GDM is increasing in a universally screened multiethnic population. The increasing GDM prevalence suggests that the vicious cycle of diabetes in pregnancy initially described among Pima Indians may also be occurring among other U.S. ethnic groups.

A comparison of rates, risk factors, and outcomes of gestational diabetes between aboriginal and non-aboriginal women in the Saskatoon health district

OBJECTIVE

To determine possible differences in gestational diabetes mellitus (GDM) between aboriginal and non-aboriginal people in the Saskatoon Health District.

RESEARCH DESIGN AND METHODS

This was a prospective survey of all women admitted for childbirth to the Saskatoon Royal University Hospital between January and July 1998. We compared prevalence rates, risk factors, and outcomes of GDM between aboriginal and non-aboriginal women.

RESULTS

Information was obtained from 2,006 women, of whom 252 aboriginal and 1,360 non-aboriginal subjects had been tested for GDM. The overall rates of GDM were 3.5% for women in the general population and 11.5% for aboriginal women. For those living within the Saskatoon Health District, GDM rates were 3.7 and 6.4%, respectively. Multivariate analysis demonstrated that aboriginal ethnicity, most notably when combined with obesity, was an independent predictor for GDM. Pregravid BMI > or = 27 kg/m(2) and maternal age > or = 33 years were the most important risk factors for GDM in aboriginal women, whereas previous GDM, family history of diabetes, and maternal age > or = 38 years were the strongest predictors for GDM in non-aboriginal women.

CONCLUSIONS

There may be fundamental differences in GDM between aboriginal and non-aboriginal people. Because GDM contributes to an increased risk for type 2 diabetes in aboriginal women and their offspring, the impact of prevention and optimal treatment of GDM on the type 2 diabetes epidemic in susceptible populations are important areas for further investigation.

High rates of infant macrosomia: a comparison of a Canadian native and a non-native population

The Cree of James Bay have the highest ever reported mean birth weight and a high prevalence of infant macrosomia. This study was designed to examine independent risk factors for infant macrosomia among the Cree, to compare these to risk factors among non-Native Canadians and to determine if ethnic differences persist after adjusting for differences in the distribution of other risk factors. Macrosomia was defined as birth weight >90(th) percentile for gestational age of a reference population. Independent determinants of macrosomia were examined in 385 Cree and 5644 non-Native women. The potential effect of ethnicity (Cree vs. non-Native) was determined after statistically adjusting for age, parity, pregravid weight, height, net rate of weight gain, gestational diabetes mellitus (GDM) and smoking status. The prevalence of macrosomia among the Cree was 34.3% vs. 11.1% among non-Natives. Although GDM significantly increased the risk for macrosomia among the Cree (odds ratio: 4.46, 95% CI: 2.24-9.26), it was not a significant risk factor among non-Natives (odds ratio: 1.15, 95% CI: 0.79-1.65). The risk for infant macrosomia remained elevated among the Cree compared with non-Natives after adjusting for other risk factors (odds ratio: 3.64, 95% CI: 2.69-4.90). In conclusion, the Cree have a high prevalence of macrosomia despite controlling for important differences in pregravid weight and GDM. Some of this variation may be due to genetic differences in fetal growth. The differential impact of GDM on macrosomia in the two ethnic groups may be due to differences in treatment strategies for GDM.

Maternal nutritional status, diabetes and risk of macrosomia among Native Canadian women

Multivariate methods were used to identify risk factors for macrosomia (birth weight > 4000 g) among 741 singleton births to Native Canadian women from Sioux Lookout Zone, Ontario, Canada, in 1990-1993. The average birth weight was 3691 +/- 577 g, and 29.2% of infants weighed more than 4000 g at birth. Macrosomic infants were born at later gestational ages and were more likely to be male. Women delivering macrosomic infants were taller, entered pregnancy with higher body mass indexes (BMI) and gained more weight during pregnancy, but were less likely to smoke cigarettes. They were more likely to have previously delivered a macrosomic infant and to have had gestational diabetes mellitus (GDM). Risk of macrosomia was associated with maternal glycemic status; women with pre-existing diabetes were at greatest risk, followed by those with GDM A2 (fasting glucose > or = 6 mmol/l). Women with GDM A1 (fasting glucose < 6 mmol/l) were not at increased risk for delivering a macrosomic infant, but glucose-tolerant women with high glucose concentrations 1 h after the 50 g challenge were at somewhat increased risk. Maternal glycemic status and maternal nutritional status before and during pregnancy are important determinants of macrosomia in this native population.

Hypertension in Alaska Natives: association with overweight, glucose intolerance, diet and mechanized activity

OBJECTIVE

Determine the prevalence of hypertension in Alaska Natives and evaluate risk factors.

DESIGN

Population-based univariate and multivariate analysis of blood pressure in 1124 Alaska Natives over 20 years of age.

RESULTS

The sample had mean: age 45 years, body mass index 27, systolic pressure 123 mmHg and diastolic pressure 73 mmHg. The age-adjusted rate of hypertension > or = 160/95 mmHg was 9.1% and 6.8% among Athabascan Indians and Yup'ik Eskimos, respectively. After controlling for age and sex there was significantly more hypertension among Athabascan Indians (OR = 1.53, CI = 1.07-2.2, p = 0.019) compared to Yup'ik Eskimos. Race was significantly associated with blood pressure > or = 140/90 when controlled for age and overweight (p = 0.01, OR = 0.78, CI = 0.69-0.95). The presence of hypertension was significantly associated with the following: intake of non-indigenous food (p = 0.01); mechanized activities (p = 0.01); and glucose intolerance in both women (p = 0.043) and men (p = 0.001). Multiple regression analysis revealed age (OR = 1.06, CI = 1.05-1.08) and overweight in both men (OR = 3.02, CI = 1.85-4.93) and women (OR = 2.76, CI = 1.81-4.19) to be significantly associated with BP > or = 140/90.

CONCLUSION

Hypertension is no longer rare in Alaska Natives and is associated with overweight, non-indigenous diet, mechanized activities, and glucose intolerance.

Dietary change and obesity associated with glucose intolerance in Alaska Natives

OBJECTIVE

To investigate frequency of food intake, body weight, and glucose intolerance in Alaska Natives.

DESIGN

Height, weight, and random blood glucose levels were measured and a frequency-of-food-intake questionnaire was obtained. This questionnaire classified persons as consumers of indigenous foods or nonindigenous foods within three food groups. Those with a random blood glucose measurement > or = 6.72 mmol/L received an oral glucose tolerance test.

SETTING

Community screening in 15 villages in Alaska.

SUBJECTS

Nutrition screenings were done for 1,124 Alaska Native residents aged 20 years or older. An oral glucose tolerance test was done for 202 subjects.

OUTCOMES MEASURED

Subjects were classified as consumers of indigenous or nonindigenous foods within three food groups. A diagnosis of non-insulin-dependent diabetes mellitus (NIDDM) was made on the basis of World Health Organization criteria. A determination of overweight was made on the basis of National Center for Health Statistics criteria.

STATISTICAL ANALYSIS

A chi 2 test with Yates correction, t test, and linear regression, with two-sided P values.

RESULTS

Athabascan Indians had twice the rate of NIDDM as Yup'ik Eskimos with significantly higher frequency of nonindigenous food intake, plus lower frequency of indigenous carbohydrate and fat intake. Subjects < or = 30 years old consumed significantly more nonindigenous protein and fat and low-nutrient-density carbohydrates than those > or = 60 years old. Persons who had glucose intolerance reported significantly greater consumption of nonindigenous protein and less seal oil. Incidence of overweight was significantly higher than was found 25 years ago. Participants with glucose intolerance were significantly more overweight than others.

CONCLUSION

A pattern of increased frequency of nonindigenous protein, low-nutrient-density carbohydrate, and fat intake with less indigenous carbohydrate and fat consumption was found in subjects < or = 30 years old and in association with the higher rate of NIDDM found in the Athabascan Indians. Persons with glucose intolerance were significantly more overweight than others.

APPLICATIONS

Although the nutritional value of indigenous foods for reducing disease risk should be promoted, nutrition education, especially among young adults, should also include building skills to select and prepare nonindigenous foods to attain a healthful diet. Although snacking is a concern, dietary fat was the most significant factor in obesity and NIDDM.

Gestational diabetes among Bedouins in southern Israel: comparison of prevalence and neonatal outcomes with the Jewish population

Differences in the prevalence of gestational diabetes mellitus (GDM) have recently been reported between various ethnic populations. In the Negev region of Israel, a universal free screening programme for GDM was implemented in 1985. Between 1 March 1987 and 31 July 1988 11,003 deliveries occurred at the Soroka Medical Center, which provides free delivery and postnatal care to the whole Jewish and Bedouin population of the region. GDM was found in 5.7% of Jewish and in 2.4% of Bedouin women (odds ratio, 2.3, 95% confidence interval (CI) 1.8-2.9; P < 0.0001). Ethnicity was unrelated to maternal outcome, perinatal mortality or to any of the examined morbidity conditions of the newborn. The incidence of major congenital malformations was significantly higher in Jewish than in Bedouin infants of GDM women (Fisher's Exact Test, P < 0.03). Conversely, Jewish infants had fewer minor congenital anomalies (odds ratio 0.26, 95% CI 0.09-0.73). In a multivariate logistic regression model, gestational age, mode of delivery and insulin requirement during pregnancy were the only factors independently associated with neonatal morbidity. The results of this study suggest that in our health care system, among women with GDM ethnicity is not associated with an excess of unfavourable maternal or infant outcomes.