Dietary Advice to Support Glycaemic Control and Weight Management in Women with Type 1 Diabetes during Pregnancy and Breastfeeding

Mean Glucose and Gestational Weight Gain as Predictors of Large-for-Gestational-Age Infants in Pregnant Women with Type 1 Diabetes Using Continuous Glucose Monitoring

Aims/hypothesis: To compare glycemic metrics during pregnancy between women with type 1 diabetes (T1D) delivering large-for-gestational-age (LGA) and appropriate-for-gestational-age (AGA) infants, and to identify predictors of LGA infants. Materials and Methods: A cohort study including 111 women with T1D using intermittently scanned continuous glucose monitoring from conception until delivery. Average sensor-derived metrics: mean glucose, time in range in pregnancy (TIRp), time above range in pregnancy, time below range in pregnancy, and coefficient of variation throughout pregnancy and in pregnancy intervals of 0-10, 11-21, 22-33, and 34-37 weeks were compared between women delivering LGA and AGA infants. Predictors of LGA infants were sought for. Infant growth was followed until 3 months postdelivery. Results: In total, 53% (n = 59) delivered LGA infants. Mean glucose decreased during pregnancy in both groups, with women delivering LGA infants having a 0.4 mmol/L higher mean glucose from 11-33 weeks (P = 0.01) compared with women delivering AGA infants. Mean TIRp >70% was obtained from 34 weeks in women delivering LGA infants and from 22-33 weeks in women delivering AGA infants. Independent predictors for delivering LGA infants were mean glucose throughout pregnancy and gestational weight gain. At 3 months postdelivery, infant weight was higher in infants born LGA compared with infants born AGA (6360 g ± 784 and 5988 ± 894, P = 0.04). Conclusions/interpretations: Women with T1D delivering LGA infants achieved glycemic targets later than women delivering AGA infants. Mean glucose and gestational weight gain were independent predictors for delivering LGA infants. Infants born LGA remained larger postdelivery compared with infants born AGA.

A Nutritional Approach to Optimizing Pump Therapy in Type 1 Diabetes Mellitus

Achieving optimal glucose control in individuals with type 1 diabetes (T1DM) continues to pose a significant challenge. While continuous insulin infusion systems have shown promise as an alternative to conventional insulin therapy, there remains a crucial need for greater awareness regarding the necessary adaptations for various special circumstances. Nutritional choices play an essential role in the efficacy of diabetes management and overall health status for patients with T1DM. Factors such as effective carbohydrate counting, assessment of the macronutrient composition of meals, and comprehending the concept of the glycemic index of foods are paramount in making informed pre-meal adjustments when utilizing insulin pumps. Furthermore, the ability to handle such situations as physical exercise, illness, pregnancy, and lactation by making appropriate adjustments in nutrition and pump settings should be cultivated within the patient-practitioner relationship. This review aims to provide healthcare practitioners with practical guidance on optimizing care for individuals living with T1DM. It includes recommendations on carbohydrate counting, managing mixed meals and the glycemic index, addressing exercise-related challenges, coping with illness, and managing nutritional needs during pregnancy and lactation. Additionally, considerations relating to closed-loop systems with regard to nutrition are addressed. By implementing these strategies, healthcare providers can better equip themselves to support individuals with T1DM in achieving improved diabetes management and enhanced quality of life.

Faster-acting insulin aspart versus insulin aspart in the treatment of type 1 or type 2 diabetes during pregnancy and post-delivery (CopenFast): an open-label, single-centre, randomised controlled trial

BACKGROUND

Faster-acting insulin aspart (faster aspart) is considered safe for use during pregnancy and breastfeeding but has not been evaluated in this population. We aimed to evaluate the effect of faster aspart versus insulin aspart on fetal growth, in women with type 1 or type 2 diabetes during pregnancy and post-delivery.

METHODS

This open-label, single-centre, superiority trial was conducted at Rigshospitalet, Copenhagen, Denmark. Participants aged 18 years or older with type 1 or type 2 diabetes were stratified by diabetes type and insulin treatment modality (multiple daily injections or insulin pump), randomly assigned 1:1 to faster aspart or insulin aspart, from 8 weeks and 0 days (8+0) of gestation to 13+6 weeks of gestation, and followed up until 3 months post-delivery. Primary outcome was infant birthweight SD score. Secondary outcomes included HbA1c as well as maternal and fetal outcomes in all participants during the trial. This trial is registered with ClinicalTrials.gov, NCT03770767.

FINDINGS

Between Nov 11, 2019 and May 10, 2022, 109 participants were included in the faster aspart group and 107 in the insulin aspart group. Primary outcome data were available in 203 (94%) of 216 participants, and no participants discontinued treatment during the trial. Mean birthweight SD score was 1·0 (SD 1·4) in the faster aspart group versus 1·2 (1·3) in the insulin aspart group; estimated treatment difference -0·22 [-0·58 to 0·14]; p=0·23. At 33 weeks of gestation, mean HbA1c was 42 mmol/mol (SD 6 mmol/mol; 6·0% [SD 0·9%]) versus 43 mmol/mol (SD 7 mmol/mol; 6·1% [SD 1·2%]); estimated treatment difference -1·01 (-2·86 to 0·83), p=0·28. No additional safety issues were observed with faster aspart compared with insulin aspart.

INTERPRETATION

Treatment with faster aspart resulted in similar fetal growth and HbA1c, relative to insulin aspart, in women with type 1 or type 2 diabetes. Faster aspart can be used in women with type 1 or type 2 diabetes during pregnancy and post-delivery with no additional safety issues.

FUNDING

Novo Nordisk.

TRANSLATION

For the Danish translation of the abstract see Supplementary Materials section.

How Maternal Nutritional and Mental Health Affects Child Health During Pregnancy: A Narrative Review

Throughout pregnancy, the mother's nutritional and mental health significantly influences the kid's long-term growth and wellness. This review's objective is to provide a comprehensive assessment of the literature on the link between pregnancy nutrition and a sound mind and a foetus' growth, considering factors in the physical, cognitive, emotional, and social domains. A balanced, nutrient-rich diet is crucial for the baby to grow and develop properly during pregnancy. An appropriate diet of significant macronutrients and micronutrients supports good foetal organ development, cognitive function, and immune system resiliency. For instance, studies have linked iron and omega-3 fatty acids to a reduced risk of developmental delays and improved cognitive performance. Contrarily, malnutrition in mothers, such as undernutrition or excessive weight gain, has been connected with negative results, including low birth weight, poor neurodevelopment, and increased susceptibility to chronic diseases in later life. The mother's mental health, including emotional equilibrium and psychological stability, significantly impacts the child's development. Stress, anxiety, and depression experienced by mothers during pregnancy harm the developing foetus and increase the risk of cognitive, behavioural, and emotional difficulties in the offspring. The growing foetus is exposed to high levels of stress hormones due to chronic maternal stress, which might alter the fetus's brain's shape and function. Factors influencing child development outcomes include maternal-infant attachment, breastfeeding start and duration, and general caring practices. A comprehensive approach is critical since new research indicates a synergistic relationship between maternal nutrition and mental health. Inadequate nutritional intake might result from maternal mental health problems that interfere with appetite control and eating habits. On the other hand, inadequate maternal nutrition may raise maternal stress and result in mental health problems. Therefore, integrative therapies focusing on both areas are essential to maximise child development results. In conclusion, maternal nutrition and mental health during pregnancy significantly impact a child's development in various domains. Understanding the complex relationships between maternal nutrition and mental health is necessary to develop effective therapies and promote the most remarkable results for children. Further research is needed to understand better the underlying mechanisms to develop evidence-based recommendations for optimal mother care throughout pregnancy. The need of this review is to know how maternal health, physical or mental affects the child's development and how we can further prevent it by taking precautions during pregnancy.

Prediction and prevention of preeclampsia in women with preexisting diabetes: the role of home blood pressure, physical activity, and aspirin

Women with type 1 or type 2 (preexisting) diabetes are four times more likely to develop preeclampsia compared with women without diabetes. Preeclampsia affects 9%-20% of pregnant women with type 1 diabetes and 7%-14% of pregnant women with type 2 diabetes. The aim of this narrative review is to investigate the role of blood pressure (BP) monitoring, physical activity, and prophylactic aspirin to reduce the prevalence of preeclampsia and to improve pregnancy outcome in women with preexisting diabetes. Home BP and office BP in early pregnancy are positively associated with development of preeclampsia, and home BP and office BP are comparable for the prediction of preeclampsia in women with preexisting diabetes. However, home BP is lower than office BP, and the difference is greater with increasing office BP. Daily physical activity is recommended during pregnancy, and limiting sedentary behavior may be beneficial to prevent preeclampsia. White coat hypertension in early pregnancy is not a clinically benign condition but is associated with an elevated risk of developing preeclampsia. This renders the current strategy of leaving white coat hypertension untreated debatable. A beneficial preventive effect of initiating low-dose aspirin (150 mg/day) for all in early pregnancy has not been demonstrated in women with preexisting diabetes.

Management of type 2 diabetes in pregnancy: a narrative review

The prevalence of type 2 diabetes (T2DM) at reproductive age is rising. Women with T2DM have a similarly high risk for pregnancy complications as pregnant women with type 1 diabetes. To reduce adverse pregnancy and neonatal outcomes, such as preeclampsia and preterm delivery, a multi-target approach is necessary. Tight glycemic control together with appropriate gestational weight gain, lifestyle measures, and if necessary, antihypertensive treatment and low-dose aspirin is advised. This narrative review discusses the latest evidence on preconception care, management of diabetes-related complications, lifestyle counselling, recommendations on gestational weight gain, pharmacologic treatment and early postpartum management of T2DM.

Management of type 1 diabetes in pregnancy: update on lifestyle, pharmacological treatment, and novel technologies for achieving glycaemic targets

Glucose concentrations within target, appropriate gestational weight gain, adequate lifestyle, and, if necessary, antihypertensive treatment and low-dose aspirin reduces the risk of pre-eclampsia, preterm delivery, and other adverse pregnancy and neonatal outcomes in pregnancies complicated by type 1 diabetes. Despite the increasing use of diabetes technology (ie, continuous glucose monitoring and insulin pumps), the target of more than 70% time in range in pregnancy (TIRp 3·5-7·8 mmol/L) is often reached only in the final weeks of pregnancy, which is too late for beneficial effects on pregnancy outcomes. Hybrid closed-loop (HCL) insulin delivery systems are emerging as promising treatment options in pregnancy. In this Review, we discuss the latest evidence on pre-pregnancy care, management of diabetes-related complications, lifestyle recommendations, gestational weight gain, antihypertensive treatment, aspirin prophylaxis, and the use of novel technologies for achieving and maintaining glycaemic targets during pregnancy in women with type 1 diabetes. In addition, the importance of effective clinical and psychosocial support for pregnant women with type 1 diabetes is also highlighted. We also discuss the contemporary studies examining HCL systems in type 1 diabetes during pregnancies.