Line Sletner

Impact of ethnicity on gestational diabetes identified with the WHO and the modified International Association of Diabetes and Pregnancy Study Groups criteria: a population-based cohort study

Objective The International Association of Diabetes and Pregnancy Study Groups (IADPSG) recently proposed new criteria for diagnosing gestational diabetes mellitus (GDM). We compared prevalence rates, risk factors, and the effect of ethnicity using the World Health Organization (WHO) and modified IADPSG criteria. Methods This was a population-based cohort study of 823 (74% of eligible) healthy pregnant women, of whom 59% were from ethnic minorities. Universal screening was performed at 28±2 weeks of gestation with the 75 g oral glucose tolerance test (OGTT). Venous plasma glucose (PG) was measured on site. GDM was diagnosed as per the definition of WHO criteria as fasting PG (FPG) ≥7.0 or 2-h PG ≥7.8 mmol/l; and as per the modified IADPSG criteria as FPG ≥5.1 or 2-h PG ≥8.5 mmol/l. Results OGTT was performed in 759 women. Crude GDM prevalence was 13.0% with WHO (Western Europeans 11%, ethnic minorities 15%, P=0.14) and 31.5% with modified IADPSG criteria (Western Europeans 24%, ethnic minorities 37%, P< 0.001). Using the WHO criteria, ethnic minority origin was an independent predictor (South Asians, odds ratio (OR) 2.24 (95% confidence interval (CI) 1.26–3.97); Middle Easterners, OR 2.13 (1.12–4.08)) after adjustments for age, parity, and prepregnant body mass index (BMI). This increased OR was unapparent after further adjustments for body height (proxy for early life socioeconomic status), education and family history of diabetes. Using the modified IADPSG criteria, prepregnant BMI (1.09 (1.05–1.13)) and ethnic minority origin (South Asians, 2.54 (1.56–4.13)) were independent predictors, while education, body height and family history had little impact. Conclusion GDM prevalence was overall 2.4-times higher with the modified IADPSG criteria compared with the WHO criteria. The new criteria identified many subjects with a relatively mild increase in FPG, strongly associated with South Asian origin and prepregnant overweight.

Metabolic Changes in Urine during and after Pregnancy in a Large, Multiethnic Population-Based Cohort Study of Gestational Diabetes

This study aims to identify novel markers for gestational diabetes (GDM) in the biochemical profile of maternal urine using NMR metabolomics. It also catalogs the general effects of pregnancy and delivery on the urine profile. Urine samples were collected at three time points (visit V1: gestational week 8–20; V2: week 28±2; V3∶10–16 weeks post partum) from participants in the STORK Groruddalen program, a prospective, multiethnic cohort study of 823 healthy, pregnant women in Oslo, Norway, and analyzed using 1H-NMR spectroscopy. Metabolites were identified and quantified where possible. PCA, PLS-DA and univariate statistics were applied and found substantial differences between the time points, dominated by a steady increase of urinary lactose concentrations, and an increase during pregnancy and subsequent dramatic reduction of several unidentified NMR signals between 0.5 and 1.1 ppm. Multivariate methods could not reliably identify GDM cases based on the WHO or graded criteria based on IADPSG definitions, indicating that the pattern of urinary metabolites above micromolar concentrations is not influenced strongly and consistently enough by the disease. However, univariate analysis suggests elevated mean citrate concentrations with increasing hyperglycemia. Multivariate classification with respect to ethnic background produced weak but statistically significant models. These results suggest that although NMR-based metabolomics can monitor changes in the urinary excretion profile of pregnant women, it may not be a prudent choice for the study of GDM.

The STORK Groruddalen research programme: A population-based cohort study of gestational diabetes, physical activity, and obesity in pregnancy in a multiethnic population. Rationale, methods, study population, and participation rates

Background: Gestational diabetes mellitus (GDM) and obesity may cause adverse pregnancy outcomes for mothers and offspring. We have set up a research programme to identify predictors for GDM and fetal growth in a multiethnic population in Oslo to improve the identification of high risk pregnancies and reduce adverse short and long-term outcomes for mothers and offspring. Aims: To present the rationale, methods, study population and participation rates. Methods: Population-based cohort study of pregnant women attending the Child Health Clinics (CHC) in Groruddalen, Oslo, and their offspring. Questionnaire data, blood pressure, anthropometric measurements, and fasting blood and urine samples are collected (gestational weeks 8—20 and 28, and 12 weeks postpartum) and an oral glucose tolerance test (28 weeks). Physical activity is measured, three ultrasound measurements are performed and paternal questionnaire data collected. Routine hospital data are available for all mothers and offspring. Umbilical venous blood and placentas are collected, sampled, and stored and neonatal anthropometric measurements performed. Ethnicity is self-reported country of birth. Results: 823 women were included, 59% of non-Western origin. The participation rate was 74% (64—83% in main ethnic groups), mean age 29.8 years (95% CI 29.5—30.1) and median parity 1 (inter-quartile range 1). The cohort is representative for women attending the CHC with respect to ethnicity and age. A slight selection towards lower parity (South Asians) and age (Africans) was found. Few were lost to follow-up. Conclusions: Unique information is collected from a representative group of multiethnic women to address important public health problems and mechanisms of disease. Participation rates are high in all ethnic groups.

Weight gain, total fat gain and regional fat gain during pregnancy and the association with gestational diabetes: a population-based cohort study

Objective:In a multi-ethnic population-based study, we investigate the change in indicators of adiposity (being weight gain and gain of total fat, truncal fat and mean skinfold thickness) from early pregnancy to 28 weeks of gestation overall and across ethnic groups, and explore the association between the change in indicators of adiposity and gestational diabetes (GDM).Design:Weight, skinfold thickness and bioelectrical impedance analysis were performed twice in 728 pregnant women in gestational week 15 (visit 1) and week 28 (visit 2). GDM was defined by the modified International Association of Diabetes in Pregnancy Study Group (IADPSG) criteria (1-hour glucose not available).Results:An increase in all indicators of adiposity gave increased odds ratios (OR) for GDM. After adjusting for pre-pregnant body mass index, a 0.14 kg per week (one standard deviation (s.d.)) increase in truncal fat gave an OR of 1.31 (95% CI 1.10–1.56), while a 0.21 kg per week (one s.d.) weight gain gave an OR of 1.23 (95% CI 1.04–1.46) for GDM. The ORs for the indicators of adiposity remained after additional adjustments for insulin resistance in early pregnancy. When combining the effects of an ethnic origin, 0.14 kg per week (one s.d.) truncal fat gain and 4.7 kg m−2 (one s.d.) increased pre-pregnant BMI the OR for South Asians was 5.9 (3.5–10.0) versus 2.1 (1.6–2.8) for Europeans.Conclusion:Weight gain and gain of total fat mass, mean skinfold thickness and especially truncal fat were all positively associated with GDM. South Asians, in particular, should be encouraged to avoid an excessive weight gain during pregnancy to reduce risk of GDM.

A prospective cohort study of depression in pregnancy, prevalence and risk factors in a multi-ethnic population

BackgroundDepression in pregnancy increases the risk of complications for mother and child. Few studies are done in ethnic minorities. We wanted to identify the prevalence of depression in pregnancy and associations with ethnicity and other risk factors.MethodPopulation-based, prospective cohort of 749 pregnant women (59% ethnic minorities) attending primary antenatal care during early pregnancy in Oslo between 2008 and 2010. Questionnaires covering demographics, health problems and psychosocial factors were collected through interviews. Depression in pregnancy was defined as a sum score ≥ 10 by the Edinburgh Postnatal Depression Scale (EPDS) at gestational week 28.ResultsThe crude prevalence of depression was; Western Europeans: 8.6% (95% CI: 5.45-11.75), Middle Easterners: 19.5% (12.19-26.81), South Asians: 17.5% (12.08-22.92), and other groups: 11.3% (6.09-16.51). Median EPDS score was 6 in Middle Easterners and 3 in all other groups.Middle Easterners (OR = 2.81; 95% CI (1.29-6.15)) and South Asians (2.72 (1.35-5.48)) had significantly higher risk for depression than other minorities and Western Europeans in logistic regression models. When adjusting for socioeconomic position and family structure, the ORs were reduced by 16-18% (OR = 2.44 (1.07-5.57) and 2.25 (1.07-4.72). Other significant risk factors were the number of recent adverse life events, self-reported history of depression and poor subjective health three months before conception.ConclusionThe prevalence of depression in pregnancy was higher in ethnic minorities from the Middle East and South Asia. The increased risk persisted after adjustment for risk factors.

Ethnic differences in neonatal body composition in a multi-ethnic population and the impact of parental factors: a population-based cohort study

Background Neonates from low and middle income countries (LAMIC) tend to have lower birth weight compared with Western European (WE) neonates. Parental height, BMI and maternal parity, age and educational level often differ according to ethnic background, and are associated with offspring birth weight. Less is known about how these factors affect ethnic differences in neonatal body composition. Objectives To explore differences in neonatal body composition in a multi-ethnic population, and the impact of key parental factors on these differences. Methods A population-based cohort study of pregnant mothers, fathers and their offspring, living in Oslo, Norway. Gender- and gestational-specific z-scores were calculated for several anthropometric measurements, with the neonates of WE ethnic origin as reference. Mean z-scores for neonates with LAMIC origin, and their parents, are presented as outcome variables. Results 537 singleton, term neonates and their parents were included. All anthropometric measurements were smaller in neonates with LAMIC origin. Abdominal circumference and ponderal index differed the most from WE (mean z-score: −0.57 (95% CI:−0.69 to −0.44) and −0.54 (−0.66 to −0.44), and remained so after adjusting for parental size. Head circumference and skin folds differed less, and length the least (−0.21 (−0.35 to −0.07)). These measures became comparable to WEs when adjusted for parental factors. Conclusions LAMIC origin neonates were relatively “thin-fat”, as indicated by reduced AC and ponderal index and relatively preserved length and skin folds, compared with neonates with WE origin. This phenotype may predispose to type 2 diabetes.

The prevalence of urinary incontinence in pregnancy among a multi-ethnic population resident in Norway.

Please cite this paper as: Bø K, Pauck Øglund G, Sletner L, Mørkrid K, Jenum A. The prevalence of urinary incontinence in pregnancy among a multi‐ethnic population resident in Norway. BJOG 2012;119:1354–1360.

Ethnic differences in maternal dietary patterns are largely explained by socio-economic score and integration score: a population-based study

Background The impact of socio-economic position and integration level on the observed ethnic differences in dietary habits has received little attention. Objectives To identify and describe dietary patterns in a multi-ethnic population of pregnant women, to explore ethnic differences in odds ratio (OR) for belonging to a dietary pattern, when adjusted for socio-economic status and integration level and to examine whether the dietary patterns were reflected in levels of biomarkers related to obesity and hyperglycaemia. Design This cross-sectional study was a part of the STORK Groruddalen study. In total, 757 pregnant women, of whom 59% were of a non-Western origin, completed a food frequency questionnaire in gestational week 28±2. Dietary patterns were extracted through cluster analysis using Wards method. Results Four robust clusters were identified where cluster 4 was considered the healthier dietary pattern and cluster 1 the least healthy. All non-European women as compared to Europeans had higher OR for belonging to the unhealthier dietary patterns 1–3 vs. cluster 4. Women from the Middle East and Africa had the highest OR, 21.5 (95% CI 10.6–43.7), of falling into cluster 1 vs. 4 as compared to Europeans. The ORs decreased substantially after adjusting for socio-economic score and integration score. A non-European ethnic origin, low socio-economic and integration scores, conduced higher OR for belonging to clusters 1, 2, and 3 as compared to cluster 4. Significant differences in fasting and 2-h glucose, fasting insulin, glycosylated haemoglobin (HbA1c), insulin resistance (HOMA-IR), and total cholesterol were observed across the dietary patterns. After adjusting for ethnicity, differences in fasting insulin (p=0.015) and HOMA-IR (p=0.040) across clusters remained significant, despite low power. Conclusion The results indicate that socio-economic and integration level may explain a large proportion of the ethnic differences in dietary patterns.

Adiposity and hyperglycaemia in pregnancy and related health outcomes in European ethnic minorities of Asian and African origin: a review

Background Ethnic minorities in Europe have high susceptibility to type 2 diabetes (T2DM) and, in some groups, also cardiovascular disease (CVD). Pregnancy can be considered a stress test that predicts future morbidity patterns in women and that affects future health of the child. Objective To review ethnic differences in: 1) adiposity, hyperglycaemia, and pre-eclampsia during pregnancy; 2) future risk in the mother of obesity, T2DM and CVD; and 3) prenatal development and possible influences of maternal obesity, hyperglycaemia, and pre-eclampsia on offsprings future disease risk, as relevant for ethnic minorities in Europe of Asian and African origin. Design Literature review. Results Maternal health among ethnic minorities is still sparsely documented. Higher pre-pregnant body mass index (BMI) is found in women of African and Middle Eastern descent, and lower BMI in women from East and South Asia compared with women from the majority population. Within study populations, risk of gestational diabetes mellitus (GDM) is considerably higher in many minority groups, particularly South Asians, than in the majority population. This increased risk is apparent at lower BMI and younger ages. Women of African origin have higher risk of pre-eclampsia. A GDM pregnancy implies approximately seven-fold higher risk of T2DM than normal pregnancies, and both GDM and pre-eclampsia increase later risk of CVD. Asian neonates have lower birth weights, and mostly also African neonates. This may translate into increased risks of later obesity, T2DM, and CVD. Foetal overgrowth can promote the same conditions. Breastfeeding represents a possible strategy to reduce risk of T2DM in both the mother and the child. Conclusions Ethnic minority women in Europe with Asian and African origin and their offspring seem to be at increased risk of T2DM and CVD, both currently and in the future. Pregnancy is an important window of opportunity for short and long-term disease prevention.

Effects of early pregnancy BMI, mid-gestational weight gain, glucose and lipid levels in pregnancy on offspring’s birth weight and subcutaneous fat: a population-based cohort study

BackgroundMaternal glucose and lipid levels are associated with neonatal anthropometry of the offspring, also independently of maternal body mass index (BMI). Gestational weight gain, however, is often not accounted for. The objective was to explore whether the effects of maternal glucose and lipid levels on offspring’s birth weight and subcutaneous fat were independent of early pregnancy BMI and mid-gestational weight gain.MethodsIn a population-based, multi-ethnic, prospective cohort of 699 women and their offspring, maternal anthropometrics were collected in gestational week 15 and 28. Maternal fasting plasma lipids, fasting and 2-hour glucose post 75 g glucose load, were collected in gestational week 28. Maternal risk factors were standardized using z-scores. Outcomes were neonatal birth weight and sum of skinfolds in four different regions.ResultsMean (standard deviation) birth weight was 3491 ± 498 g and mean sum of skinfolds was 18.2 ± 3.9 mm. Maternal fasting glucose and HDL-cholesterol were predictors of birth weight, and fasting and 2-hour glucose were predictors of neonatal sum of skinfolds, independently of weight gain as well as early pregnancy BMI, gestational week at inclusion, maternal age, parity, smoking status, ethnic origin, gestational age and offspring’s sex. However, weight gain was the strongest independent predictor of both birth weight and neonatal sum of skinfolds, with a 0.21 kg/week increased weight gain giving a 110.7 (95% confidence interval 76.6-144.9) g heavier neonate, and with 0.72 (0.38-1.06) mm larger sum of skinfolds. The effect size of mother’s early pregnancy BMI on birth weight was higher in non-Europeans than in Europeans.ConclusionsMaternal fasting glucose and HDL-cholesterol were predictors of offspring’s birth weight, and fasting and 2-hour glucose were predictors of neonatal sum of skinfolds, independently of weight gain. Mid-gestational weight gain was a stronger predictor of both birth weight and neonatal sum of skinfolds than early pregnancy BMI, maternal glucose and lipid levels.