N. Wah Cheung

Sociodemographic Correlates of the Increasing Trend in Prevalence of Gestational Diabetes Mellitus in a Large Population of Women Between 1995 and 2005

OBJECTIVE—Gestational diabetes mellitus (GDM) is an increasingly prevalent risk factor for the development of type 2 diabetes in the mother and is responsible for morbidity in the child. To better identify women at risk of developing GDM we examined sociodemographic correlates and changes in the prevalence of GDM among all births between 1995 and 2005 in Australias largest state. RESEARCH DESIGN AND METHODS—A computerized database of all births (n = 956,738) between 1995 and 2005 in New South Wales, Australia, was used in a multivariate logistic regression that examined the association between sociodemographic characteristics and the occurrence of GDM. RESULTS—Between 1995 and 2005, the prevalence of GDM increased by 45%, from 3.0 to 4.4%. Women born in South Asia had the highest adjusted odds ratio (OR) of any region (4.33 [95% CI 4.12–4.55]) relative to women born in Australia. Women living in the three lowest socioeconomic quartiles had higher adjusted ORs for GDM relative to women in the highest quartile (1.54 [1.50–1.59], 1.74 [1.69–1.8], and 1.65 [1.60–1.70] for decreasing socioeconomic status quartiles). Increasing age was strongly associated with GDM, with women aged >40 years having an adjusted OR of 6.13 (95% CI 5.79–6.49) relative to women in their early 20s. Parity was associated with a small reduced risk. There was no association between smoking and GDM. CONCLUSIONS—Maternal age, socioeconomic position, and ethnicity are important correlates of GDM. Future culturally specific interventions should target prevention of GDM in these high-risk groups.

Thyrotoxicosis induced by alpha‐interferon therapy in chronic viral hepatitis

background and objective It has been well documented that treatment of chronic hepatitis B and C infection with interferon alpha (IFN‐α) can lead to the induction of thyroid autoantibodies and hypothyroidism. Thyrotoxicosis, however, is less frequently observed and less well characterized.

The management of gestational diabetes.

The incidence of gestational diabetes is increasing. As gestational diabetes is associated with adverse pregnancy outcomes, and has long-term implications for both mother and child, it is important that it is recognized and appropriately managed. This review will examine the pharmacological options for the management of gestational diabetes, as well as the evidence for blood glucose monitoring, dietary and exercise therapy. The medical management of gestational diabetes is still evolving, and recent randomized controlled trials have added considerably to our knowledge in this area. As insulin therapy is effective and safe, it is considered the gold standard of pharmacotherapy for gestational diabetes, against which other treatments have been compared. The current experience is that the short acting insulin analogs lispro and aspart are safe, but there are only limited data to support the use of long acting insulin analogs. There are randomized controlled trials which have demonstrated efficacy of the oral agents glyburide and metformin. Whilst short-term data have not demonstrated adverse effects of glyburide and metformin on the fetus, and they are increasingly being used in pregnancy, there remain long-term concerns regarding their potential for harm.

Psychosocial Factors Related to Diet Among Women with Recent Gestational Diabetes Opportunities for Intervention

Purpose This study investigated postpartum dietary behaviors among women with recent gestational diabetes mellitus (GDM), the cognitive and social factors related to these, and preferred types of lifestyle support, in order improve the development of diabetes prevention strategies for this group. Methods Participants were a random sample of 226 women diagnosed with GDM in the prior 6 to 24 months. Telephone surveys were used to evaluate dietary behaviors, self-efficacy, social support, perceived barriers to healthy eating, and preferred methods of lifestyle support. Results Only 5% of the respondents consumed 5 servings/day of vegetables and 44% consumed 2 or more servings/day of fruit. Fried food was eaten at least twice per week by 26% of women and 50% usually consumed full-fat milk. Higher vegetable consumption was associated with self-efficacy to cook healthy foods, reporting that a healthy diet is not a difficult change and that dislike of healthy foods by other household members is not a barrier. Fruit consumption was positively related to self-efficacy when busy and when not reporting a dislike of healthy foods by others at home. Advice from a dietitian and telephone support from a health educator were the most preferred forms of health assistance. Conclusions Dietary risks factors are prevalent among women with recent GDM. Confidence and skills in cooking healthy foods, along with family food preferences and time pressures, are important influences on eating habits. Dietary change programs, informed by the beliefs and circumstances of this high-risk population, need to be developed.

Comparison of Hemoglobin A1c With Fasting Plasma Glucose and 2-h Postchallenge Glucose for Risk Stratification Among Women With Recent Gestational Diabetes Mellitus

OBJECTIVE Postpartum testing with a 75-g 2-h oral glucose tolerance test or fasting plasma glucose (FPG) alone is often not performed among women with histories of gestational diabetes mellitus (GDM). Use of hemoglobin A1c (A1C) might increase testing. The association between A1C and glucose has not been examined in women with histories of GDM. RESEARCH DESIGN AND METHODS We assessed the association of A1C ≥5.7% with FPG ≥100 mg/dL and 2-h glucose ≥140 mg/dL among 54 women with histories of GDM between 6 weeks and 36 months postpartum. RESULTS A1C ≥5.7% had 65% sensitivity and 68% specificity for identifying elevated FPG or 2-h glucose and 75% sensitivity and 62% specificity for elevated FPG alone. The area under the receiver operating characteristic curve for A1C was 0.76 for elevated FPG or 2-h glucose and 0.77 for elevated FPG alone. CONCLUSIONS The agreement between A1C and glucose levels is fair for detection of abnormal glucose tolerance among women with histories of GDM.

Mother to child transmission of diabetes mellitus: does gestational diabetes program Type 2 diabetes in the next generation?

Aim  Type 2 diabetes is frequently familial. Hyperglycaemia in pregnancy might act in addition to genetic factors to cause diabetes in the children of mothers with gestational diabetes mellitus (GDM). The first manifestation of this in female offspring is likely to be GDM in their own pregnancies. We compared the incidence of GDM in daughters of diabetic mothers and diabetic fathers to determine if in utero exposure to hyperglycaemia increased the risk of a diabetes‐prone phenotype in offspring.

Point: Universal Screening for Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is one of the most common medical disorders found in pregnancy. Rates can range from 2 to >10%, and sometimes much higher, depending on the population being tested and the diagnostic criteria being used (1). The prevalence of GDM ultimately reflects the background rate of type 2 diabetes. There has also been an increase in the rate of GDM over the last generation, possibly related to community lifestyle factors as well as better case ascertainment (2,3). ### Significance of GDM GDM is associated with a trilogy of risks. Significant pregnancy complications including increased perinatal morbidity and possibly mortality can occur (4,5). A diagnosis of GDM also identifies a mother at high risk for the future development of type 2 diabetes (1). The effects of maternal hyperglycemia (of any kind) are associated with the development of metabolic problems including type 2 diabetes in the offspring (6). It is, perhaps, for this effect of intrauterine programming that the disorder is most worthy of detection. It has now been demonstrated that the treatment of GDM improves pregnancy outcomes. In the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS), the incidence of serious perinatal complications (a composite of death, shoulder dystocia, nerve palsy, and fracture) was 4% among women randomized to routine care compared with 1% among the intervention group (5). The number of GDM cases that needed to be treated to prevent one serious perinatal complication was 34. This indicates that excess serious perinatal complications will occur in 3% of cases of untreated or unrecognized GDM. This is a most compelling immediate argument for the screening of GDM given that the failure to identify a woman with GDM denies her the opportunity to have treatment for potentially preventable serious fetal complications. ### Why conduct selective screening for GDM? Therefore, if we accept that GDM is …

Vitamin D Supplementation and the Effects on Glucose Metabolism During Pregnancy: A Randomized Controlled Trial

OBJECTIVE Vitamin D deficiency in pregnancy is associated with an increased risk of gestational diabetes mellitus (GDM) and neonatal vitamin D deficiency. We conducted a double-blind, randomized controlled trial of low-dose (LD) versus high-dose (HD) vitamin D supplementation to investigate the effects of vitamin D supplementation on glucose metabolism during pregnancy. RESEARCH DESIGN AND METHODS Women with plasma 25-hydroxyvitamin D (25OHD) levels <32 ng/mL before 20 weeks’ gestation were randomized to oral vitamin D3 at 5,000 IU daily (HD) (n = 89) or the recommended pregnancy dose of 400 IU daily (LD) (n = 90) until delivery. The primary end point was maternal glucose levels on oral glucose tolerance test (OGTT) at 26–28 weeks’ gestation. Secondary end points included neonatal 25OHD, obstetric and other neonatal outcomes, and maternal homeostasis model assessment of insulin resistance. Analysis was by intention to treat. RESULTS There was no difference in maternal glucose levels on OGTT. Twelve LD women (13%) developed GDM versus seven (8%) HD women (P = 0.25). Neonatal cord 25OHD was higher in HD offspring (46 ± 11 vs. 29 ± 12 ng/mL, P < 0.001), and deficiency was more common in LD offspring (24 vs. 10%, P = 0.06). Post hoc analysis in LD women showed an inverse relationship between pretreatment 25OHD and both fasting and 2-h blood glucose level on OGTT (both P < 0.001). Baseline 25OHD remained an independent predictor after multiple regression analysis. CONCLUSIONS HD vitamin D supplementation commencing at a mean of 14 weeks’ gestation does not improve glucose levels in pregnancy. However, in women with baseline levels <32 ng/mL, 5,000 IU per day was well tolerated and highly effective at preventing neonatal vitamin D deficiency.

The role of HbA1c in the diagnosis of diabetes mellitus in Australia

For many years, the diagnosis of diabetes has been made through the laboratory‐based measurement of fasting or random blood glucose levels, or using the oral glucose tolerance test. A glycated haemoglobin (HbA1c) level ≥ 6.5% (48 mmol/mol) is now also acceptable for diagnosing diabetes. Caution is needed in interpreting HbA1c test results in the presence of conditions affecting red blood cells or their survival time, such as haemoglobinopathies or anaemia.

Type 2 diabetes in pregnancy: a wolf in sheep's clothing.

Type 2 diabetes is now the most common form of pregestational diabetes. Recent data suggest that pregnancies complicated by type 2 diabetes are associated with unacceptably high fetal mortality and morbidity, at an incidence comparable to pregnancies complicated by type 1 diabetes. This review examines the literature on type 2 diabetes in pregnancy, including its incidence and potential complications. There is a need to highlight the dangers of type 2 diabetes in pregnancy to both patients and medical practitioners. Peri‐conception care needs to improve to achieve better pregnancy outcomes.