Anne Dornhorst

High Prevalence of Gestational Diabetes in Women from Ethnic Minority Groups

The influence of ethnic origin, body mass index, and parity on the frequency of gestational diabetes was assessed in 11205 consecutive women attending a multiracial antenatal clinic in London, where all women were screened for gestational diabetes. Logistic regression was used to model the relationship between gestational diabetes and ethnic origin, age, body mass index (BMI), and parity. Results were presented as adjusted odds ratios, where the reference categories are White women, age < 25 years, BMI < 27, and parity < 3. Ethnic origin was the dominant influence on the prevalence of gestational diabetes. Women from ethnic groups other than White had a higher frequency of gestational diabetes than White women (2.9% vs 0.4%, p < 0.001). Compared to White women the relative risk of gestational diabetes in the other ethnic groups was: Black 3.1 (95% confidence limits 1.8–5.5), South East Asian 7.6 (4.1–14.1), Indian 11.3 (6.8–18.8), and miscellaneous 5.9 (3.5–9.9). Increasing age was an independent risk factor. The relative risk was higher in women ≥ 35 years in all ethnic groups other than in South East Asian women. Obesity (BMI ≥ 27) was a further independent risk factor in all ethnic groups except in the Indian and South East Asian women. Parity ≥ 3 increased the relative risk of gestational diabetes in the White, Black, and South East Asian women only. Age and obesity were factors of particular importance in Black women in whom the risk was 4.1 fold greater in those ≥ 35 years compared with women ≥ 35 years, and 5.0 fold higher if the BMI was ≥ 27 compared with ≥ 27. Ethnic origin has a major influence on the prevalence of gestational diabetes and the importance of other risk factors varies between ethnic groups. These findings have important implications for the screening of women in pregnancy.

A randomised four-intervention crossover study investigating the effect of carbohydrates on daytime profiles of insulin, glucose, non-esterified fatty acids and triacylglycerols in middle-aged men

Postprandial concentrations of glucose, insulin and triacylglycerols (TG) correlate to risk for CHD. Carbohydrates affect many metabolites that could have a potential effect on cardiovascular risk factors. The objective of the present study was to examine, using a randomised prospective study, the acute (day 1) and ad libitum medium-term (day 24) effects of four diets: a high-fat diet (HIGH-FAT; 50 % fat, >34 % monounsaturated fatty acids); a low-glycaemic index (GI) diet (LOW-GI; high-carbohydrate, low-GI); a high-sucrose diet (SUCROSE; high carbohydrate increase of 90 g sucrose/d); a high-GI diet (HIGH-GI; high-carbohydrate, high-GI). Daytime profiles (8 h) (breakfast, lunch and tea) of lipid and carbohydrate metabolism were completed during day 1 and day 24. Seventeen middle-aged men with one or more cardiac risk factors completed the study. There was no change from day 1 or between diets in fasting glucose, lipids or homeostatic assessment model (HOMA) on day 24. The HIGH-FAT compared with the three high-carbohydrate diets was associated with lower postprandial insulin and glucose but higher postprandial TG and non-esterified fatty acids (NEFA). There was a significant increase in the 6 h (15.00 hours) TG concentration (day 1, 2.6 (sem 0.3) mmol/l v. day 24, 3.3 (sem 0.3) mmol/l; P<0.01) on the SUCROSE diet. Postprandial HOMA (i.e. incremental area under the curve (IAUC) glucose (mmol/l per min)xIAUC insulin/22.5 (mU/l per min)) median changes from day 1 to day 24 were -61, -43, -20 and +31 % for the HIGH-FAT, LOW-GI, SUCROSE and HIGH-GI diets respectively. The HIGH-GI percentage change was significantly different from the other three diets (P<0.001). Despite being advised to maintain an identical energy intake there was a significant weight change (-0.27 (sem 0.3) kg; P<0.02) on the LOW-GI diet compared with the SUCROSE diet (+0.84 (sem 0.3) kg). In conclusion the HIGH-FAT diet had a beneficial effect on postprandial glucose and insulin over time but it was associated with higher postprandial concentrations of TG and NEFA. Conversely the HIGH-GI diet appeared to increase postprandial insulin resistance over the study period.

The relevance of the glycaemic index to our understanding of dietary carbohydrates

Aims To review the evidence for the importance of glycaemic index of dietary carbohydrate in disease prevention and control

Insulin detemir improves glycaemic control without weight gain in insulin-naive patients with type 2 diabetes : subgroup analysis from the PREDICTIVE™ study

Objective: Predictable Results and Experience in Diabetes through Intensification and Control to Target: an International Variability Evaluation (PREDICTIVETM) is a multi‐national, open‐label, prospective, observational study assessing the safety and efficacy of insulin detemir in clinical practice. This post hoc subanalysis evaluates insulin‐naïve patients on oral antidiabetic drugs (OADs) who were initiated on insulin detemir as basal therapy (± OADs).

PREDICTIVE™ -a global, prospective observational study to evaluate insulin detemir treatment in types 1 and 2 diabetes : baseline characteristics and predictors of hypoglycaemia from the european cohort

Aim:  PREDICTIVE™ (Predictable Results and Experience in Diabetes through Intensification and Control to Target: An International Variability Evaluation) is a large, multi‐national, observational study assessing the safety and efficacy of insulin detemir. We report the study design, population characteristics and baseline observations, including cross‐sectional analysis, from 19 911 patients with type 1 or 2 diabetes.

Assessing glycemic control in maintenance hemodialysis patients with type 2 diabetes.

OBJECTIVE Optimizing glycemic control in diabetic patients undergoing maintenance hemodialysis requires accurate assessment. We hypothesize that 1) 48-h continuous glucose monitoring (CGM) provides additional, clinically relevant, information to that provided by the A1C measurement and 2) glycemic profiles differ significantly between day on and day off dialysis. RESEARCH DESIGN AND METHODS With the use of GlucoDay S, 48-h CGM was performed in 19 type 2 diabetic subjects undergoing hemodialysis to capture consecutive 24-h periods on and off dialysis. Energy intake was calculated using food diaries. A1C was assayed by a high-performance liquid chromatography method. RESULTS CGM data were available for 17 subjects (13 male) with a mean (range) age of 61.5 years (42–79 years) and diabetes duration of 18.8 years (4–30 years). The 24-h CGM area under the glucose curve and 24-h mean glucose values were significantly higher during the day off dialysis than on dialysis (5,932.1 ± 2,673.6 vs. 4,694 ± 1,988.0 mmol · 3 min−1 · l−1, P = 0.022, and 12.6 ± 5.6 vs. 9.8 ± 3.8 mmol/l, P = 0.013, respectively), independent of energy intake. Asymptomatic hypoglycemia occurred in 4 subjects, 3 within 24 h of dialysis, and the glucose nadir in 14 subjects occurred within 24 h of dialysis. CONCLUSIONS Glucose values are significantly lower on dialysis days than on nondialysis days despite similar energy intake. The risk of asymptomatic hypoglycemia was highest within 24 h of dialysis. Physicians caring for patients undergoing hemodialysis need to be aware of this phenomenon and consider enhanced glycemic monitoring after a hemodialysis session. CGM provides glycemic information in addition to A1C, which is potentially relevant to clinical management.

EFFECT OF TREATMENT WITH SODIUM VALPROATE AND DIAZEPAM ON PLASMA CORTICOTROPIN IN NELSON'S SYNDROME

Six patients with Nelsons syndrome were given sodium valproate with or without diazepam for 3 or 5 weeks. Initial high plasma adrenocorticotropic hormone (ACTH) concentrations were greatly reduced by treatment and returned to high levels when treatment was stopped. Diazepam did not add significantly to the effects of sodium valproate alone. Three patients reported a decrease in the severity and frequency of headaches while on sodium valproate. In five patients abnormal skin pigmentation was reduced. Sodium valproate is a gamma-aminobutyric acid (GABA) transaminase inhibitor and it is suggested that the drug raises GABA levels in the hypothalamus and that this is responsible for the reduction in ACTH secretion. The data are consistent with the hypothesis that Nelsons syndrome is a neuroendocrine disease caused by a deficiency in the hypothalamic GABA-ergic system.

Transferring to insulin detemir from NPH insulin or insulin glargine in type 2 diabetes patients on basal-only therapy with oral antidiabetic drugs improves glycaemic control and reduces weight gain and risk of hypoglycaemia: 14-week follow-up data from PREDICTIVE™

Aim:  The aim of this study was to evaluate the safety and efficacy of insulin detemir in type 2 diabetes patients previously receiving NPH insulin (NPH group, n = 175) or insulin glargine (glargine group, n = 118) in combination with oral antidiabetic drugs (OADs).

A prospective randomised trial to determine the efficacy of a low glycaemic index diet given in addition to healthy eating and weight loss advice in patients with coronary heart disease.

Objective: Recent epidemiological and prospective trial evidence suggests that consumption of a low glycaemic index (LGI) diet will reduce coronary risk. We hypothesise that introduction of an LGI diet will improve the metabolic profile of patients who have undergone coronary artery bypass grafting.Design: We conducted a randomised parallel group trial comparing a control group (n=29, age 61.8±9 y), who received currently advocated healthy eating dietary advice only, to an intervention group, who received healthy eating advice emphasising LGI carbohydrates (n=26, age 63.6±9.4 y) over a 12-week period in free-living patients with coronary heart disease. Outcome measures included fasting glucose, insulin, total cholesterol, high-density lipoprotein cholesterol, very low-density lipoprotein cholesterol, low density lipoprotein cholesterol and triglycerides.Results: A significant lower dietary glycaemic index was achieved in the group assigned to an LGI diet compared to the healthy eating control group (71±1 vs 81±1); fibre intake was also higher in the LGI group (20±1 vs 15±1 g). All biochemical markers of glucose and lipid metabolism measured were similar after 12 weeks of the LGI diet or control diet.Discussion: The LGI group achieved a significant LGI and a higher dietary fibre intake. However, there was no measurable significant effect of either the LGI diet or the health eating diet on lipid levels; this may have been hidden by concurrent drug therapy.

Veganism and its relationship with insulin resistance and intramyocellular lipid

Objective: To test the hypothesis that dietary factors in the vegan diet lead to improved insulin sensitivity and lower intramyocellular lipid (IMCL) storage.Design: Case–control study.Setting: Imperial College School of Medicine, Hammersmith Hospital Campus, London, UK.Subjects: A total of 24 vegans and 25 omnivores participated in this study; three vegan subjects could not be matched therefore the matched results are shown for 21 vegans and 25 omnivores. The subjects were matched for gender, age and body mass index (BMI).Interventions: Full anthropometry, 7-day dietary assessment and physical activity levels were obtained. Insulin sensitivity (%S) and beta-cell function (%B) were determined using the homeostatic model assessment (HOMA). IMCL levels were determined using in vivo proton magnetic resonance spectroscopy; total body fat content was assessed by bioelectrical impedance.Results: There was no difference between the groups in sex, age, BMI, waist measurement, percentage body fat, activity levels and energy intake. Vegans had a significantly lower systolic blood pressure (−11.0 mmHg, CI −20.6 to −1.3, P=0.027) and higher dietary intake of carbohydrate (10.7%, CI 6.8–14.5, P<0.001), nonstarch polysaccharides (20.7 g, CI 15.8–25.6, P<0.001) and polyunsaturated fat (2.8%, CI 1.0–4.6, P=0.003), with a significantly lower glycaemic index (−3.7, CI −6.7 to −0.7, P=0.01). Also, vegans had lower fasting plasma triacylglycerol (−0.7 mmol/l, CI −0.9 to −0.4, P<0.001) and glucose (−0.4 mmol/l, CI −0.7 to −0.09, P=0.05) concentrations. There was no significant difference in HOMA %S but there was with HOMA %B (32.1%, CI 10.3–53.9, P=0.005), while IMCL levels were significantly lower in the soleus muscle (−9.7, CI −16.2 to −3.3, P=0.01).Conclusion: Vegans have a food intake and a biochemical profile that will be expected to be cardioprotective, with lower IMCL accumulation and beta-cell protective.Sponsorship: MRC PhD studentship.