Smoking and mortality among women with type 2 diabetes: The Nurses' Health Study cohort.

OBJECTIVE: To assess the relationship between cigarette smoking and mortality among women with type 2 diabetes in the Nurses' Health Study cohort. RESEARCH DESIGN AND METHODS: The Nurses' Health Study, a prospective cohort of U.S. female registered nurses, included 7,401 women with type 2 diabetes diagnosed at baseline or during follow-up from 1976 to 1996. Total and cause-specific mortality of these diabetic women were the outcomes of interest. RESULTS: We documented 724 deaths during 20 years of follow-up (67,420 person-years) among women with type 2 diabetes. In multivariate analyses, adjusting for age, history of high blood pressure and high cholesterol, and other cardiovascular risk factors, compared with never smokers, the RRs of mortality were 1.31 (95% CI 1.11-1.55) for past smokers, 1.43 (0.96-2.14) for current smokers of 1-14 cigarettes/day, 1.64 (1.24-2.17) for current smokers of 15-34 cigarettes/day, and 2.19 (1.32-3.65) for current smokers of > or =35 cigarettes/day (P for trend = 0.0002). Women with type 2 diabetes who had stopped smoking for > or =10 years had a mortality RR of 1.11 (0.92-1.35) compared with diabetic women who were never smokers. CONCLUSIONS: Cigarette smoking is associated in a dose-response manner with an increased mortality among women with type 2 diabetes. Furthermore, quitting smoking appears to decrease this excess risk substantially. Diabetes patients should be strongly advised against smoking.     

Gestational diabetes mellitus in women of single gravidity in Tianjin City, China

OBJECTIVE: The aim of this study was to investigate the prevalence of gestational diabetes mellitus (GDM) and risk factors for the development of GDM in pregnant women in Tianjin, China, where the prevalence of GDM is still unknown. STUDY DESIGN AND METHODS: A total of 9,471 pregnant women living in the six urban districts of Tianjin, China, took part in the initial screening between December 1998 and December 1999. The screening test consisted of a 50-g 1-h glucose test. Women with a reading > or =7.8 mmol/l at the initial screening were invited to undergo a 75-g 2-h oral glucose tolerance test (OGTT). GDM was confirmed using the World Health Organization's diagnostic criteria. RESULTS: At the initial screening test, 888 women had a glucose reading of > or =7.8 mmol/l. A total of 701 (79%) women took a subsequent OGTT. Of these, 174 women were confirmed to have GDM (154 with impaired glucose tolerance [IGT] and 20 with diabetes). The prevalence of GDM was 2.31% (2.03% for IGT and 0.28% for diabetes), adjusting for serum glucose levels at the initial screening test. Independent predictors for GDM were maternal age, stature, prepregnancy BMI, weight gain in pregnancy before screening, diabetes in first-degree relatives, and habitual cigarette smoking during pregnancy. Women who smoked or had a short stature are more likely to develop GDM than their counterparts. CONCLUSIONS: The prevalence of GDM in pregnant women in the city of Tianjin, China, was 2.31%. Short stature and smoking in pregnancy were additional risk factors for GDM.     

First-trimester C-reactive protein and subsequent gestational diabetes

OBJECTIVE: Systemic inflammation is associated with the development of type 2 diabetes. We tested the hypothesis that increased inflammation, measured early in pregnancy, is associated with the subsequent development of gestational diabetes mellitus (GDM), a precursor of type 2 diabetes. RESEARCH DESIGN AND METHODS: We conducted a prospective nested case-control study in a pregnancy cohort. First-trimester C-reactive protein (CRP) levels were measured using a high-resolution assay in 43 women who subsequently developed GDM and in a random sample of 94 women who remained euglycemic throughout pregnancy. Median CRP levels were compared using Wilcoxon's rank-sum test. Logistic regression was used to compute unadjusted and multivariable-adjusted odds ratios for developing GDM among CRP tertiles. RESULTS: First-trimester CRP levels were significantly increased among women who subsequently developed GDM compared with control subjects (3.1 vs. 2.1 mg/l, P < 0.01). The risk of developing GDM among women in the highest CRP tertile compared with the lowest tertile was 3.2 (95% CI 1.2-8.8). After adjusting for age, race/ethnicity, smoking, parity, blood pressure, and gestational age at CRP sampling, the risk of developing GDM among women in the highest compared with the lowest tertile was 3.6 (95% CI 1.2-11.4). When BMI was included in the model, however, the association between increased CRP and GDM was attenuated (odds ratio for the highest compared with lowest tertile 1.5 [95% CI 0.4-5.5]). CONCLUSIONS: In women who develop GDM, there is evidence of increased inflammation during the first trimester. This association is mediated in part by increased BMI. Larger studies are needed to verify these results.     

Smoking as a modifiable risk factor for type 2 diabetes in middle-aged men

OBJECTIVE: To examine the effects of cigarette smoking, giving up smoking, and primary or secondary pipe or cigar smoking on the risk of type 2 diabetes. RESEARCH DESIGN AND METHODS: A prospective study followed 7,735 men aged 40-59 years from general practices in 24 British towns for an average of 16.8 years. Incident cases of physician-diagnosed diabetes were ascertained by repeated postal questionnaires and systematic reviews of primary care records. RESULTS: A total of 290 incident cases of diabetes were found in 7,124 men with no history of diabetes, coronary heart disease, or stroke. Cigarette smoking was associated with a significant increase in risk of diabetes, even after adjustment for age, BMI, and other potential confounders. The benefit of giving up smoking was only apparent after 5 years of smoking cessation, and risk reverted to that of never-smokers only after 20 years. The risk of diabetes in those who switched from smoking cigarettes to pipe or cigars remained equal to the risk in continuing cigarette smokers. Men who gave up smoking during the first 5 years of follow-up showed significant weight gain and subsequently higher risk of diabetes than continuing smokers. CONCLUSIONS: Cigarette smoking is an independent and modifiable risk factor for type 2 diabetes. Smoking cessation is associated with weight gain and a subsequent increase in risk of diabetes, but in the long term, the benefits of giving up smoking outweigh the adverse effects of early weight gain.     

Population health significance of gestational diabetes

OBJECTIVE: Women who have had gestational diabetes mellitus (GDM) have a high risk of subsequently developing diabetes. However, the contribution of GDM toward the total population of people with diabetes, or its population health impact, has not been examined. Therefore, the aim of this study is to determine the population health significance of GDM by estimating the proportion of cases of diabetes in women that would have been preceded by a pregnancy complicated by GDM. RESEARCH DESIGN AND METHODS: A MEDLINE search was conducted to identify controlled follow-up studies of women with GDM. Meta-analysis of these studies, using the Mantel-Haenszel method for pooling relative risks (RRs), provided an overall RR for the development of diabetes in women with GDM versus control women who had been pregnant without GDM. Recent large studies examining the prevalence of GDM were also reviewed. This enabled the calculation of the population-attributable risk (PAR) for these populations. In this case, the PAR represents the proportion of cases of diabetes among parous women that were associated with previous GDM. RESULTS: From six controlled follow-up studies, the overall RR for developing diabetes after GDM was calculated to be 6.0 (95% CI 4.1-8.8). Applying this to the studies of GDM prevalence, the PAR for GDM ranged from 0.10 to 0.31 (i.e., 10-31% of parous women with diabetes would have experienced a GDM pregnancy earlier). CONCLUSIONS: In some populations, women who have had GDM comprise a substantial proportion of subjects who ultimately develop diabetes. Effective measures to prevent women with GDM from progressing to frank diabetes could therefore have a significant population health impact.     

Effect of smoking on pregnancy-associated plasma protein A, free β-human chorionic gonadotropin, and nuchal translucency in the first trimester of pregnancy

Data were collected from 1275 pregnant Turkish women screened prospectively for chromosomal anomalies to determine whether first-trimester levels of maternal serum pregnancy-associated plasma protein A (PAPP-A) and free β-human chorionic gonadotropin (β-hCG) and the thickness of nuchal translucency are affected by smoking and other covariables. Only normal singleton pregnancies were included. After weight correction, comparisons were made between smokers and nonsmokers. Mean values of PAPP-A and β-hCG were reduced in women who smoked 5 or more cigarettes a day compared with nonsmokers. The median β-hCG level decreased significantly as gravidity and parity increased; no effect was noted on PAPP-A. Median PAPP-A and β-hCG levels tended to increase, but not significantly in women who had had 2 or more miscarriages. Smoking alters maternal levels of serum analytes, with the magnitude of the impact related to the number of cigarettes smoked per day. This effect can be detected in the first trimester of pregnancy.     

Gestational diabetes mellitus: is a diagnosis associated with an increase in maternal anxiety and stress in the short and intermediate term?

OBJECTIVE: To examine anxiety levels of women diagnosed with gestational diabetes mellitus (GDM) and to compare these with glucose-tolerant (GT) women at similar stages of pregnancy. RESEARCH DESIGN AND METHODS: Prospective longitudinal study conducted on 50 women with GDM and 50 GT women. All women completed the Mental Health Inventory (MHI-5) forms and the Speilberger State-Trait Anxiety Inventory (STAI) at the beginning of the third trimester, antepartum, and 6 weeks postpartum. Specific questions were also assessed using a Likert scale. RESULTS: Women with GDM, compared with GT women, had a higher level of anxiety (state rather than trait) at the time of the first assessment. However, before delivery and in the postpartum period, there were no significant differences in anxiety scores between the two groups. Women in both groups were positive about being tested for GDM and wished to be tested during future pregnancies. CONCLUSIONS: There were no sustained increased levels of anxiety for women diagnosed with GDM. Concerns expressed about causing sustained maternal anxiety by testing for GDM could not be substantiated.     

Gestational Diabetes Mellitus Alone in the Absence of Subsequent Diabetes Is Associated With Microalbuminuria: Results from the Kidney Early Evaluation Program (KEEP)

OBJECTIVE

Women with gestational diabetes mellitus (GDM) maintain a higher risk for recurrent GDM and overt diabetes. Overt diabetes is a risk factor for development of chronic kidney disease (CKD), but GDM alone, without subsequent development of overt diabetes, may also pose a risk for CKD.

RESEARCH DESIGN AND METHODS

This cross-sectional analysis included Kidney Early Evaluation Program (KEEP) participants from 2000 to 2009. Patient characteristics and kidney function among three categories (GDM alone, overt diabetes, and no history of diabetes) were compared. The prevalence of microalbuminuria, macroalbuminuria, and CKD stages 1–2 and 3–5 was assessed using logistic regression.

RESULTS

Of 37,716 KEEP female participants, 571 (1.5%) had GDM alone and 12,100 (32.1%) had overt diabetes. Women with GDM had a higher rate of microalbuminuria but not macroalbuminuria than their nondiabetic peers (10.0 vs. 7.7%) that was substantially lower than the 13.6% prevalence in diabetic women. In multivariate analysis, women with GDM alone, compared with nondiabetic women, demonstrated increased odds of CKD stages 1–2 (multivariate odds ratio 1.54 [95% CI 1.16–2.05]) similar to the odds for women with overt diabetes (1.68 [1.55–1.82]). In stratified analyses, age, race, BMI, and hypertension modified the odds for CKD stages 1 –2 but not CKD stages 3–5 among women with GDM.

CONCLUSIONS

Women with GDM alone have a higher prevalence of microalbuminuria than women without any history of diabetes, translating to higher rates of CKD stages 1–2. These results suggest that GDM, even in the absence of subsequent overt diabetes, may increase the risk for future cardiovascular and kidney disease.Most women who develop diabetes during a pregnancy, gestational diabetes mellitus (GDM), are normoglycemic after delivery but still maintain a higher risk for recurrent GDM, impaired glucose tolerance, and overt diabetes. Indeed, the odds of developing subsequent type 2 diabetes for women with GDM is roughly 5 times higher than that for women with normoglycemic pregnancies in the first 5 years after delivery; the odds rise to more than 9 times higher in the years afterward (1).Although overt diabetes is recognized as a potent risk factor for development of chronic kidney disease (CKD), it is currently unclear whether GDM alone, without subsequent development of overt diabetes, also poses any risk to kidney function. Because certain clinical factors (e.g., waist circumference, BMI, and years postdelivery) have been shown to increase the risk for development of overt diabetes in women with GDM (2), these factors could potentially also modify the risk for development of CKD.We hypothesized that GDM alone would impart an increased risk for CKD and, specifically, that women with GDM would have a level of risk intermediate between that of women without any history of glucose abnormalities and women with overt diabetes. Using data from the National Kidney Foundation''s Kidney Early Evaluation Program (KEEP), a program designed to screen participants at higher risk for CKD than the general population, we examined in cross-sectional analyses whether GDM, in the absence of subsequent overt diabetes, increases the odds of abnormal urinary albumin excretion and impaired glomerular filtration rate. In addition, we examined whether age, race, BMI, or hypertension modifies this relationship between GDM and CKD.     

After Gestational Diabetes: An Overlooked Care Transition in Primary Care

Women with history of gestational diabetes mellitus (GDM) have significant risk for developing type 2 diabetes (T2D), especially within 6 years of giving birth. Children exposed to GDM-complicated pregnancies may also experience future metabolic abnormalities. Care transitions following GDM-complicated pregnancies are often fragmented resulting in missed opportunities to implement T2D prevention strategies. Primary care providers of women with history of GDM and their children have opportunities to deliver transgenerational health promotion interventions encompassing: T2D screening, reproductive life planning, lifestyle changes to support reduction of GDM-related metabolic risks, self-advocacy for lifelong T2D screening, weight management, and promotion of breastfeeding.     

Prospective Study of Pre-Gravid Sugar-Sweetened Beverage Consumption and the Risk of Gestational Diabetes Mellitus

OBJECTIVE

Consumption of sugar-sweetened beverages (SSBs) was related to an elevated risk of type 2 diabetes and insulin resistance in several recent studies among middle- or older-aged populations. Studies on SSB consumption and glucose intolerance among pregnant women, however, are lacking. We therefore examined the association between regular SSB consumption before pregnancy and the risk of gestational diabetes mellitus (GDM).

RESEARCH DESIGN AND METHODS

This was a prospective study among 13,475 U.S. women who reported at least one singleton pregnancy between 1992 and 2001 in the Nurses'' Health Study II. GDM was self-reported and validated by medical record review in a subsample. Cox proportional hazards models with multivariate adjustments were applied to examine the association of SSB consumption with GDM risk.

RESULTS

During 10 years of follow-up, 860 incident GDM case subjects were identified. After adjustment for age, parity, race, physical activity, smoking, alcohol intake, prepregnancy BMI, and Western dietary pattern, intake of sugar-sweetened cola was positively associated with the risk of GDM, whereas no significant association was found for other SSBs and diet beverages. Compared with women who consumed <1 serving/month, those who consumed ≥5 servings/week of sugar-sweetened cola had a 22% greater GDM risk (relative risk 1.22 [95% CI 1.01–1.47]).

CONCLUSIONS

Findings from this study suggest that prepregnancy higher consumption of sugar-sweetened cola (≥5 servings/week) is associated with an elevated GDM risk, whereas no significant association with GDM risk was observed for other SSBs and diet beverages.Gestational diabetes mellitus (GDM), defined as glucose intolerance with onset or first recognition during pregnancy, is one of the most common pregnancy complications (1). Women with GDM are at increased risk of pregnancy complications, perinatal morbidity, and type 2 diabetes in the years after pregnancy. Offspring of women with GDM have increased risk of obesity, glucose intolerance, and diabetes in childhood and early adulthood (1). Despite the maternal and infant morbidity associated with GDM, limited attention has been paid to the identification of dietary risk factors for GDM.Sugar-sweetened beverages (SSBs) are the leading source of added sugars in Americans'' diets (2). In animal models and human studies, a high-sugar diet reduces insulin sensitivity (3,4) and insulin secretion (5). Higher consumption of SSBs was associated with an elevated risk of type 2 diabetes (6–8) and insulin resistance (9) among middle- or older-aged adults in several recent epidemiological studies. Studies regarding the impact of habitual SSB consumption on glucose intolerance among pregnant women, however, are lacking. We therefore examined the association of pregravid SSB consumption with GDM risk in a large prospective cohort of U.S. women.     

Gestational diabetes: Is there a relationship between leg length and glucose tolerance?

OBJECTIVE: To assess the relationship between leg length and glucose tolerance in pregnancy. RESEARCH DESIGN AND METHODS: The leg length and leg-to-height percentage were prospectively determined on 161 glucose-tolerant women during pregnancy and 61 women with gestational diabetes mellitus (GDM). RESULTS: Women with GDM were a mean of 2.8 cm shorter than women who were glucose tolerant, due entirely to their leg lengths being a mean of 3.2 cm shorter. With respect to the 2-h result on the glucose tolerance test (GTT), there were negative correlations for height (r = -0.161, P = 0.017), leg length (r = -0.266, P < 0.0005), and the leg-to-height percentage (r = -0.294, P < 0.0005). The correlation between the leg-to-height percentage and the 2-h result on the GTT remained significant after adjustment for age (r = -0.252, P < 0.0005) and for age and BMI (r = -0.224, P = 0.001). CONCLUSIONS: Women with GDM are shorter than glucose-tolerant women and have a lower leg-to-height percentage. Consideration of short stature as a risk factor for GDM is not valid without taking into account the leg-to-height percentage.     

Pregravid Liver Enzyme Levels and Risk of Gestational Diabetes Mellitus During a Subsequent Pregnancy

OBJECTIVE

Liver enzymes are independent predictors of type 2 diabetes. Although liver fat content correlates with features of insulin resistance, a risk factor for developing gestational diabetes mellitus (GDM), the relationship between liver enzymes and GDM is unclear. The objective of this study was to assess whether pregravid liver enzyme levels are associated with subsequent risk of GDM.

RESEARCH DESIGN AND METHODS

A nested case-control study was conducted among women who participated in the Kaiser Permanente Northern California multiphasic health checkup (1984–1996) and had a subsequent pregnancy (1984–2009). Case patients were 256 women who developed GDM. Two control subjects were selected for each case patient and matched for year of blood draw, age at examination, age at pregnancy, and number of intervening pregnancies.

RESULTS

Being in the highest quartile versus the lowest quartile of γ-glutamyl transferase (GGT) levels was associated with a twofold increased risk of subsequent GDM (odds ratio 1.97 [95% CI 1.14–3.42]), after adjusting for race/ethnicity, prepregnancy BMI, family history of diabetes, and alcohol use. This result was attenuated after adjusting for homeostasis model assessment of insulin resistance (HOMA-IR), fasting status, and rate of gestational weight gain. There was significant interaction between GGT and HOMA-IR; the association with GGT was found among women in the highest tertile of HOMA-IR. Aspartate aminotransferase and alanine aminotransferase were not associated with increased GDM risk.

CONCLUSIONS

Pregravid GGT level, but not alanine aminotransferase or aspartate aminotransferase level, predicted the subsequent risk of GDM. Markers of liver fat accumulation, such as GGT level, are present years before pregnancy and may help to identify women at increased risk for subsequent GDM.     

Subsequent pregnancy after gestational diabetes mellitus: frequency and risk factors for recurrence in Korean women

OBJECTIVE—The purpose of this study was to determine the frequency of recurrent gestational diabetes mellitus (GDM) and to find risk factors that can predict the recurrence of GDM in Korean women with previous GDM.RESEARCH DESIGN AND METHODS—We evaluated women who had GDM in an index pregnancy (1993–2001) and a subsequent pregnancy by 2003. An oral glucose tolerance test (OGTT) was performed during the index pregnancy and 2 months postpartum. The recurrence rate of GDM was assessed among 111 women who had a subsequent pregnancy. Multivariate logistic regression analysis was used to identify independent predictors of recurrent GDM.RESULTS—The frequency of recurrent GDM in subsequent pregnancies was 45.0% (95% CI 35.6–54.4%). Women with impaired fasting glucose and/or impaired glucose tolerance 2 months postpartum were at increased risk for recurrent GDM (relative risk 2.31, 95% CI 1.24–4.30). Higher BMI before the subsequent pregnancy (P = 0.024), higher fasting glucose concentration (P = 0.007) 2 months postpartum, and lower 1-h insulin concentration (P = 0.004) of the diagnostic OGTT in the index pregnancy were independent risk factors for recurrence of GDM in subsequent pregnancies.CONCLUSIONS—GDM recurred in nearly half of subsequent pregnancies in Korean women. Fasting glucose 2 months postpartum might be a clinically valuable predictor of recurrent GDM risk.Gestational diabetes mellitus (GDM) is defined as glucose intolerance of variable severity with onset or first recognition during pregnancy (1). GDM is associated with adverse outcomes of pregnancy such as preeclampsia, cesarean delivery, macrosomia, and birth trauma (1,2). Furthermore, women with GDM and their offspring are at increased risk for the development of diabetes later in life (3–5). Recently, a randomized clinical trial demonstrated that treatment of maternal hyperglycemia significantly reduced perinatal morbidity in GDM (6). If we could identify risk factors for recurrent GDM, we might possibly prevent its recurrence. It may also be possible to reduce perinatal morbidity by early diagnosis and optimal treatment of recurrent GDM during the subsequent pregnancy.The reported frequency of recurrent GDM varies widely, from 30 to 84%, depending on the ethnicity of the subjects and the diagnostic criteria used (7). Although one study reported the recurrence rate of GDM in Asian women (8), the sample size was small and widely used diagnostic criteria for GDM were not applied.Risk factors associated with recurrence of GDM have also varied among reported studies (7,9). In general, greater maternal age, obesity, degree of hyperglycemia in the index pregnancy, increased weight gain, and short interval between pregnancies were suggested to be associated with recurrent GDM (7–11). However, biochemical parameters, such as glucose and insulin levels during pregnancy and/or early postpartum, have not often been evaluated as risk factors for recurrence of GDM. It is recommended that women with GDM have a glucose tolerance test to reevaluate glycemic status at the first postpartum visit (12). We hypothesized that the early postpartum glucose concentration might provide important information for predicting risk of recurrence of GDM. In this study we evaluated the recurrence rate of GDM in Korean women and risk factors for its recurrence, including a postpartum oral glucose tolerance test (OGTT).     

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 Australia''s 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.Type 2 diabetes affects an estimated 246 million individuals worldwide—a figure that is predicted to increase to 380 million by 2025, with a disproportionate number of affected individuals living in lower- and middle-income countries of the Asia-Pacific region (1). Diabetes is a major cardiovascular risk factor, more than doubling the risk of having a stroke or heart attack. Moreover, diabetes appears to be particularly hazardous in women, as there is a 50% greater risk of dying from coronary heart disease compared with that of men with the same condition (2).Gestational diabetes mellitus (GDM), defined as glucose intolerance first detected during pregnancy, is a strong predictor of type 2 diabetes. Women with GDM are up to six times more likely to develop type 2 diabetes than women with normal glucose tolerance in pregnancy (3). The incidence of GDM varies among populations, similar to the variation of type 2 diabetes, with recent prevalence estimates ranging from 2.8% of pregnant women in Washington, DC, to 18.9% in India and 22% in Sardinia, Italy (4). The risk for GDM increases with age, and incidence rates vary by ethnicity within a population, again similar to the risk for type 2 diabetes (4,5). There is also evidence that obesity, parity, smoking, and family history are risk factors for GDM (5). However, less is known regarding the sociodemographic distribution of GDM. Given the strong link between GDM and the subsequent risk of diabetes for the mother and the perinatal morbidity for mother and child—an association recently updated with findings of a continuous association of maternal glucose levels and adverse perinatal outcomes by the Hyperglycemia and Adverse Pregnancy Outcomes Study Cooperative Research Group (6)—a better understanding of the sociodemographic determinants of GDM may provide novel opportunities to reduce the incidence and to prevent the onset of type 2 diabetes in later life.Most studies that have examined the etiology of GDM have been hospital based or have been based on samples of births in a particular region (4,5). There are currently no large, comprehensive population-wide urban and rural datasets that have been collected in an attempt to examine multiple risk factors for GDM over a number of years and no population-based studies outside the U.S. The New South Wales (NSW) Midwives Dataset has information on nearly 1 million births in the state of NSW during the period from 1995 to 2005 in a health system in which there is almost universal screening for GDM. This dataset was used to study the current and changing population rates of GDM and its associated sociodemographic risk factors in a large, ethnically diverse population of women.     

Persistence of Risk for Type 2 Diabetes After Gestational Diabetes Mellitus

OBJECTIVEGestational diabetes mellitus complicates ∼6% of pregnancies and strongly predicts subsequent type 2 diabetes. It has not been fully elucidated how risk depends on the number of affected pregnancies or how long the excess risk persists.RESEARCH DESIGN AND METHODSWe assessed reproductive histories in relation to risk of type 2 diabetes using a nationwide cohort of 50,884 women. Among participants who initially did not have diabetes, 3,370 were diagnosed with diabetes during 10 years of follow-up. We used Cox proportional hazards models that allowed risk to depend on age, cumulative number of pregnancies with gestational diabetes mellitus, and time since the most recent affected pregnancy, adjusting for BMI, educational level, and race/ethnicity.RESULTSHistory of one or more pregnancies with gestational diabetes mellitus predicted elevated age-specific risk of type 2 diabetes, with a hazard ratio of 3.87 (95% CI 2.60–5.75) 6–15 years after an affected pregnancy. Risk increased steeply with multiple affected pregnancies. The age-specific associations attenuated over time after an affected pregnancy, with an estimated 24% reduction of the hazard ratio per decade. Risk remained elevated, however, for >35 years.CONCLUSIONSGestational diabetes mellitus predicted markedly increased rates of type 2 diabetes. Relative risk increased substantially with each additional affected pregnancy. The estimated hazard ratio declined with time after a pregnancy with gestational diabetes mellitus but remained elevated for >35 years. Women recalling a history of gestational diabetes mellitus should be screened regularly for type 2 diabetes, even late in life.     

Understanding exercise beliefs and behaviors in women with gestational diabetes mellitus

OBJECTIVE: The purpose of this study was to examine the exercise beliefs and behaviors of postpartum women who had gestational diabetes mellitus (GDM) during a recent pregnancy. RESEARCH DESIGN AND METHODS: Postpartum women with GDM (n = 28) completed a mail survey assessing their self-reported exercise beliefs (advantages, barriers, and important social influences) and behaviors. RESULTS: We found that 1) the strongest perceived advantage of exercise during pregnancy was controlling blood glucose and postpartum it was controlling weight, 2) the most common barrier to exercise during pregnancy was fatigue and postpartum it was a lack of time, 3) women's husband/partner most strongly influenced their exercise during pregnancy and postpartum, 4) women exercised more during the postpartum period than before or during pregnancy, and 5) the number of exercise advantages was positively associated with women's pregnancy and postpartum exercise behavior. CONCLUSIONS: To increase exercise behavior and reduce the risk of type 2 diabetes in women with GDM, researchers and health care professionals are encouraged to use women's exercise beliefs, that is, advantages, social influences, and perceived barriers to exercise, as a framework for designing effective diabetes treatment and prevention programs.     

Cigarette smoking and risk of pressure ulcer in adult intensive care unit patients

The objective of this study was to assess relationship between smoking, some other risk factors and ulcers development in intensive care unit. This prospective cohort study was performed in two university‐affiliated hospitals. The sample consisted of adult male patients who were admitted to medical–surgical intensive care units. All eligible patients were grouped according to their cigarette smoking status as smoker and non‐smoker. The final sample included 160 smokers and 192 non‐smokers. Pressure ulcer occurred in 62 smoker patients and 28 of non‐smoker who showed significant difference. Also number of pack‐year of cigarettes smoking showed significant association with ulcer development. Ulcer stage was significantly different between the two groups. Besides of smoking, age, length of stay, faecal incontinency, diabetes mellitus, anaemia and trauma were significantly associated with pressure ulcers. Our study showed significant association between smoking and development of pressure ulcers.     

Gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is defined as glucose intolerance of various degrees that is first detected during pregnancy. GDM is detected through the screening of pregnant women for clinical risk factors and, among at-risk women, testing for abnormal glucose tolerance that is usually, but not invariably, mild and asymptomatic. GDM appears to result from the same broad spectrum of physiological and genetic abnormalities that characterize diabetes outside of pregnancy. Indeed, women with GDM are at high risk for having or developing diabetes when they are not pregnant. Thus, GDM provides a unique opportunity to study the early pathogenesis of diabetes and to develop interventions to prevent the disease.     

2588例孕妇糖耐量筛查及相关因素分析

目的：调查上海市某三级医院妊娠期糖尿病(GDM)的发病率并探讨其发病的危险因素。方法：采用回顾性研究的方法,选取该院2014年1月至12月分娩的孕妇作为研究对象,通过查阅病史的方式收集数据,运用t检验、卡方检验及二元Logistic回归分析进行数据分析。结果：(1)GDM的发病率为9.3%,GDM组的平均年龄高于非GDM组(P=0.000),且年龄分组也有明显差异(P=0.000);(2)GDM组孕期增重低于非GDM组(P=0.000),GDM组在产次和胎数上与非GDM组有差异(P=0.027、P=0.000),但在是否流产上无统计学差异(P=0.271);(3)GDM组平均红细胞数、血红蛋白水平高于非GDM组(P=0.024 、P=0.001);(4)Logistic回归分析显示,孕妇年龄增长、双胎和血红蛋白水平较高是GDM的独立危险因素。结论：孕妇年龄增长、双胎是GDM的独立危险因素。     

Association between passive and active smoking and incident type 2 diabetes in women

OBJECTIVE

Accumulating evidence has identified a positive association between active smoking and the risk of diabetes, but previous studies had limited information on passive smoking or changes in smoking behaviors over time. This analysis examined the association between exposure to passive smoke, active smoking, and the risk of incident type 2 diabetes among women.

RESEARCH DESIGN AND METHODS

This is a prospective cohort study of 100,526 women in the Nurses’ Health Study who did not have prevalent diabetes in 1982, with follow-up for diabetes for 24 years.

RESULTS

We identified 5,392 incident cases of type 2 diabetes during 24 years of follow-up. Compared with nonsmokers with no exposure to passive smoke, there was an increased risk of diabetes among nonsmokers who were occasionally (relative risk [RR] 1.10 [95% CI 0.94–1.23]) or regularly (1.16 [1.00–1.35]) exposed to passive smoke. The risk of incident type 2 diabetes was increased by 28% (12–50) among all past smokers. The risk diminished as time since quitting increased but still was elevated even 20–29 years later (1.15 [1.00–1.32]). Current smokers had the highest risk of incident type 2 diabetes in a dose-dependent manner. Adjusted RRs increased from 1.39 (1.17–1.64) for 1–14 cigarettes per day to 1.98 (1.57–2.36) for ≥25 cigarettes per day compared with nonsmokers with no exposure to passive smoke.

CONCLUSIONS

Our study suggests that exposure to passive smoke and active smoking are positively and independently associated with the risk of type 2 diabetes.Smoking is one of the leading causes of avoidable death globally (1). The disease burden attributable to smoking already is enormous, with ~6 million premature deaths worldwide each year, and is projected to grow substantially across the century without an end to the pandemic (1). Diabetes also is a global health priority. The International Diabetes Federation has predicted that the number of individuals with diabetes will increase from 240 million in 2007 to 380 million in 2025 (2).Accumulating evidence has identified a positive association between active smoking and risk of type 2 diabetes (3), whereas few studies had information on passive smoking. Data from the Third National Health and Nutrition Examination Survey 1988–1991 suggest that ~90% of nonsmokers have detectable levels of serum cotinine, a sensitive marker for tobacco exposure (4). Therefore, previous studies linking active smoking with diabetes risk might have underestimated the magnitude of the true association because individuals exposed to passive smoke would be in the reference group. The few studies that simultaneously examined the relative associations of passive and active smoking on diabetes risk (5,6) were limited by relatively short follow-up periods, limited information on potential confounders, and lack of information on smoking quantity or change in smoking behavior over time. Therefore, we prospectively investigated the association between passive and active smoking and the risk of incident type 2 diabetes over 24 years of follow-up among 100,526 women from the Nurses’ Health Study (NHS).