Increased risk of cardiovascular disease in young women following gestational diabetes mellitus

OBJECTIVE—To determine whether women with gestational diabetes mellitus (GDM) have an increased risk of cardiovascular disease (CVD) following pregnancy.RESEARCH DESIGN AND METHODS—All women aged 20–49 years with live births between April 1994 and March 1997 in Ontario, Canada, were identified. Women with GDM were matched with 10 women without GDM and were followed for CVD.RESULTS—The matched cohorts included 8,191 women with GDM and 81,262 women without GDM. Mean age at entry was 31 years, and median follow-up was 11.5 years. The hazard ratio for CVD events was 1.71 (95% CI 1.08–2.69). After adjustment for subsequent type 2 diabetes, the hazard ratio was attenuated (1.13 [95% CI 0.67–1.89]).CONCLUSIONS—Young women with GDM had a substantially increased risk for CVD compared with women without GDM. Much of this increased risk was attributable to subsequent development of type 2 diabetes.Gestational diabetes mellitus (GDM) is a common condition affecting 2–4% of pregnant women (1) and is associated with adverse outcomes for both the fetus and the mother. Previous GDM is a major risk factor for type 2 diabetes, which occurs in 20–60% of affected women within 5 years of the pregnancy (2). Women with a history of GDM are also at increased risk of other cardiovascular risk factors, such as obesity, hypertension, dyslipidemia, and the metabolic syndrome (3–5), as well as subclinical atherosclerosis (6). Taken together, these findings suggest that GDM identifies a population of young women at increased risk for cardiovascular disease (CVD). We used population-based administrative data to determine whether women with GDM have a heightened risk for CVD compared with women without GDM and whether any increase in risk is independent of subsequent type 2 diabetes.     

Diabetes and obesity-related risks for pelvic reconstructive surgery in a cohort of Swedish twins

OBJECTIVE—To determine the diabetes- and obesity-related risks for surgically managed stress urinary incontinence and pelvic organ prolapse.RESEARCH DESIGN AND METHODS—This twin cohort study used the Swedish Twin Register to identify 8,443 female twin pairs born from 1926 through 1958. The association between diabetes and pelvic floor surgery was estimated while taking into account the correlated (twin) structure of the data.RESULTS—For type 1 and type 2 diabetes, no significant associations were observed for stress urinary incontinence (odds ratio [OR] 1.0 [95% CI 0.1–9.2] and 2.0 [1.0–4.0], respectively). There were no cases of prolapse surgery in type 1 diabetic subjects, and for type 2 diabetes the risk estimate was nonsignificant (1.6 [1.0–2.7]). BMI >25 kg/m², age ≥60 years, and childbirth were the strongest risk factors for having incontinence surgery.CONCLUSIONS—Our data suggest that diabetes is not associated with stress urinary incontinence or pelvic organ prolapse surgery.The estimated 11% lifetime risk of female pelvic reconstructive surgery in U.S. women mainly comprises stress urinary incontinence and pelvic organ prolapse surgery (1). In addition to the health-economic burden on society, pelvic floor disorders are associated with often severe implications regarding quality of life (2).Diabetes and obesity are often promoted as risk factors for urogenital disorders (3,4), but previous studies are limited by cross-sectional study designs (5–7). Some studies do not differentiate between diabetes or incontinence types (3), and genetic influences on the association are unknown.Genetic effects may contribute to the occurrence of both pelvic floor disorders and diabetes (8,9). Using twin data, the association between diabetes and development of pelvic floor disorders can be estimated while taking into account the genetically correlated (twin) structure of the data. We used the nationwide Swedish Twin Register to estimate the risk of diabetes and obesity on stress urinary incontinence and pelvic organ prolapse surgery.     

Factors associated with intensification of oral diabetes medications in primary care provider-patient dyads: a cohort study

OBJECTIVE—Although suboptimal glycemic control is known to be common in diabetic adults, few studies have evaluated factors at the level of the physician-patient encounter. Our objective was to identify novel visit-based factors associated with intensification of oral diabetes medications in diabetic adults.RESEARCH DESIGN AND METHODS—We conducted a nonconcurrent prospective cohort study of 121 patients with type 2 diabetes and hyperglycemia (A1C ≥8%) enrolled in an academically affiliated managed-care program. Over a 24-month interval (1999–2001), we identified 574 hyperglycemic visits. We measured treatment intensification and factors associated with intensification at each visit.RESULTS—Provider-patient dyads intensified oral diabetes treatment in only 128 (22%) of 574 hyperglycemic visits. As expected, worse glycemia was an important predictor of intensification. Treatment was more likely to be intensified for patients with visits that were “routine” (odds ratio [OR] 2.55 [95% CI 1.49–4.38]), for patients taking two or more oral diabetes drugs (2.82 [1.74–4.56]), or for patients with longer intervals between visits (OR per 30 days 1.05 [1.00–1.10]). In contrast, patients with less recent A1C measurements (OR >30 days before the visit 0.53 [0.34–0.85]), patients with a higher number of prior visits (OR per prior visit 0.94 [0.88–1.00]), and African American patients (0.59 [0.35–1.00]) were less likely to have treatment intensified.CONCLUSIONS—Failure to intensify oral diabetes treatment is common in diabetes care. Quality improvement measures in type 2 diabetes should focus on overcoming inertia, improving continuity of care, and reducing racial disparities.Although glycemic control reduces microvascular complications and may reduce macrovascular complications (1–3), diabetic patients commonly have inadequately controlled blood glucose (4–8). Recent evidence suggests that lack of intensification of diabetes medications in a timely fashion is a powerful explanatory factor (4–6,9–11). This decision to intensify treatment may be affected by several factors, such as patient adherence (12) and preference, competing medical demands (13), or provider attitudes and knowledge (14).Identifying barriers and promoters of treatment intensification is a crucial first step toward developing strategies to improve blood glucose control in diabetic adults. Although many studies have documented lack of adequate glycemic control (4–8) and failures to intensify medications in subjects with diabetes (4–6,9–11), few studies have evaluated factors associated with treatment intensification besides glycemic control (13,15,16). Of these studies, two evaluated a variety of visit-based factors associated with intensification, but these had limited generalizability (13,15) and did not adjust for key confounders such as patient adherence (13). No study has focused in detail on a variety of visit-based factors in addition to patient and provider factors that might influence oral diabetes treatment intensification.Therefore, we conducted a nonconcurrent prospective cohort study to identify novel barriers and promoters of intensification of oral diabetes medications in type 2 diabetic adults. We felt these visit-based factors may be more modifiable than durable patient and physician factors such as age or sex.     

Adipokines and incident type 2 diabetes in an Aboriginal Canadian [corrected] population: the Sandy Lake Health and Diabetes Project

OBJECTIVE—The aim of this study was to investigate associations of adiponectin, leptin, C-reactive protein (CRP), interleukin (IL)-6, and serum amyloid A (SAA), individually or in combinations, with risk of incident type 2 diabetes in a Canadian Aborigine population.RESEARCH DESIGN AND METHODS—Of the 606 Sandy Lake Health and Diabetes Project cohort subjects who were free of diabetes at baseline, 540 (89.1%) participated in 10-year follow-up assessments. Concentrations of fasting adiponectin, leptin, CRP, IL-6, SAA, and covariates were measured at baseline. Fasting glucose and a 75-g oral glucose tolerance test were obtained at baseline and follow-up to determine incident type 2 diabetes, defined as clinically diagnosed type 2 diabetes or as fasting plasma glucose ≥7.0 mmol/l or 2-h postload plasma glucose ≥11.1 mmol/l at follow-up.RESULTS—Low adiponectin, high leptin, and low adiponectin-to-leptin ratio at baseline were associated with increased risk of incident type 2 diabetes after adjustment for age, sex, triglycerides, HDL cholesterol, hypertension, and impaired glucose tolerance (odds ratio 0.63 [95% CI 0.48–0.83], 1.50 [1.02–2.21], and 0.54 [0.37–0.77], respectively). When the models were additionally adjusted for waist circumference or BMI, however, only low adiponectin remained significantly associated with increased incident diabetes (0.68 [0.51–0.90]). Combinations of leptin, CRP, IL-6, and/or SAA with adiponectin, assessed using either the ratio or joint effects, did not improve diabetes prediction.CONCLUSIONS—Low baseline adiponectin is associated with increased risk of incident type 2 diabetes independent of leptin, CRP, IL-6, SAA, and metabolic syndrome variables including obesity.Obesity is a major risk factor for insulin resistance and type 2 diabetes (1). The recent focus on adipose tissue as an endocrine organ secreting signaling proteins, collectively termed adipokines, has prompted current interests in associations of adipokines with insulin resistance and diabetes (1–2). Although underlying mechanisms have not been completely explained, adipokines have been linked with obesity-induced inflammation and signaling pathways that contribute to type 2 diabetes (1). Prospectively, adiponectin, an anti-inflammatory, anti-atherogenic, and insulin-sensitizing adipokine (2,3), has been inversely associated with the development of type 2 diabetes (4–7). Several studies associated increased baseline levels of inflammatory markers, including interleukin (IL)-6 (8,9) and C-reactive protein (CRP) (9), with incident type 2 diabetes, while others reported no association of IL-6 (4) and CRP (4,8) with the development of type 2 diabetes after adjustment for adiposity measures. In another prospective study, the association between leptin and diabetes risk was attenuated after adjustment for intra-abdominal fat (10).Recent studies have suggested that adipokines may interact in regulating metabolic homeostasis (11–12). In a cross-sectional study, evidence was presented for CRP inhibiting the binding of leptin to its receptors and leptin stimulating expression of CRP (11). Others identified the adiponectin-to-leptin (A/L) ratio as a reliable marker of insulin resistance (12).Nonetheless, limited population-based data are available on how adipokines in combinations may contribute to the etiology of diabetes. In addition, previous prospective investigations on associations of adipokines with diabetes provide inconsistent findings (4–10). Among those, only a few have reported data from studies of North American Aboriginal people (4,5), while no studies have been conducted among Aboriginal Canadians in whom diabetes is increasingly prevalent (13). The objective of this study was to investigate associations of baseline adiponectin, leptin, CRP, IL-6, and serum amyloid A (SAA), individually and/or in combinations, with the development of type 2 diabetes in a Canadian Aborigine population undergoing rapid cultural transition.     

Diabetes, glycemic control, and risk of hospitalization with pneumonia: a population-based case-control study

OBJECTIVE—To examine whether diabetes is a risk factor for hospitalization with pneumonia and to assess the impact of A1C level on such risk.RESEARCH DESIGN AND METHODS—In this population-based, case-control study we identified patients with a first-time pneumonia-related hospitalization between 1997 and 2005, using health care databases in northern Denmark. For each case, 10 sex- and age-matched population control subjects were selected from Denmark''s Civil Registration System. We used conditional logistic regression to compute relative risk (RR) for pneumonia-related hospitalization among subjects with and without diabetes, controlling for potential confounding factors.RESULTS—The study included 34,239 patients with a pneumonia-related hospitalization and 342,390 population control subjects. The adjusted RR for pneumonia-related hospitalization among subjects with diabetes was 1.26 (95% CI 1.21–1.31) compared with nondiabetic individuals. The adjusted RR was 4.43 (3.40–5.77) for subjects with type 1 diabetes and 1.23 (1.19–1.28) for subjects with type 2 diabetes. Diabetes duration ≥10 years increased the risk of a pneumonia-related hospitalization (1.37 [1.28–1.47]). Compared with subjects without diabetes, the adjusted RR was 1.22 (1.14–1.30) for diabetic subjects whose A1C level was <7% and 1.60 (1.44–1.76) for diabetic subjects whose A1C level was ≥9%.CONCLUSIONS—Type 1 and type 2 diabetes are risk factors for a pneumonia-related hospitalization. Poor long-term glycemic control among patients with diabetes clearly increases the risk of hospitalization with pneumonia.Hospitalizations with pneumonia have increased by 20–50% in Western populations during the past 10 years (1,2). Combined with influenza, pneumonia is the seventh leading cause of death in the U.S. (3).Diabetes is thought to be a risk factor for pneumonia, but available data are few and inconclusive (4–11). Diabetic subjects may have increased susceptibility to pneumonia for several reasons. They are at increased risk of aspiration, hyperglycemia, decreased immunity, impaired lung function, pulmonary microangiopathy, and coexisting morbidity (12). Five cohort studies (4,6,8–10) found that diabetes is a risk factor for pneumonia, with relative risks (RRs) ranging from 1.30 to 1.75, while three studies (5,7,11) failed to find an association. Existing studies have limitations: some included only patients aged >60 years (8,10,11), one did not adjust for comorbidity (9), and few were population-based (9,11). Only one study (6) of respiratory tract infections distinguished between type 1 and type 2 diabetes.Immunologic abnormalities in diabetic subjects are related in part to the harmful effects of hyperglycemia (12). Recently, a cohort study (4) encompassing 10,063 subjects followed for 7 years found that each 1 mmol/l increase in baseline plasma glucose was associated with a 6% increase in the RR of pneumonia. However, this result was based on a single nonfasting glucose measurement. The impact of poor long-term glycemic control on risk of pneumonia-related hospitalization still remains uncertain.Given the rising incidence of pneumonia-related hospitalizations (1,2) and the increasing prevalence of diabetes (13), it is important to clarify whether diabetes and poor long-term glycemic control is a risk factor for pneumonia. We examined whether diabetes is associated with an increased risk of pneumonia-related hospitalization and whether this risk is modulated by A1C level.     

Relationship between risk factors and mortality in type 1 diabetic patients in Europe: the EURODIAB Prospective Complications Study (PCS)

OBJECTIVE—The purpose of this study was to examine risk factors for mortality in patients with type 1 diabetes.RESEARCH DESIGN AND METHODS—Baseline risk factors were measured in the EURODIAB Prospective Cohort Study with 2,787 type 1 diabetic patients (51% men and 49% women) recruited from 16 European countries. Mortality data were collected during a 7-year follow-up.RESULTS—There was an annual mortality rate of 5 per 1,000 person-years in patients with type 1 diabetes (mean age at baseline 33 years, range 15–61 years); of the total 2,787 subjects, 102 died. The final multivariable model contained age at baseline (standardized hazard ratio 1.78 [95% CI 1.44–2.20]), A1C (1.18 [0.95–1.46]), waist-to-hip ratio (WHR) (1.32 [1.14–1.52]), pulse pressure (1.33 [1.13–1.58]), and non-HDL cholesterol (1.33 [1.12–1.60]) as risk factors for all-cause mortality. Macroalbuminuria (2.39 [1.19–4.78]) and peripheral (1.88 [1.06–3.35]) and autonomic neuropathy (2.40 [1.32–4.36]) were the most important risk markers for mortality. Similar risk factors were found for all-cause, non-cardiovascular disease (CVD), unknown-cause, and CVD mortality.CONCLUSIONS—Important risk factors for the increased total and non-CVD mortality in type 1 diabetic patients are age, WHR, pulse pressure, and non-HDL cholesterol. Microvascular complications from macroalbuminuria and peripheral and autonomic neuropathy are strong risk markers for future mortality exceeding the effect of the traditional risk factors.The presence of type 1 diabetes is associated with a three- to fourfold increased risk of mortality compared with that of the general population (1,2). It is still not clear what risk factors explain this excess mortality risk. We have shown that risk factors associated with insulin resistance, such as triglyceride, waist-to-hip ratio (WHR), and albuminuria strongly predict cardiovascular disease (CVD) in type 1 diabetes (3). Although CVD is the major cause of death in patients with type 1 diabetes, it only accounts for approximately half of all deaths, and it is therefore important to study the totality of risk and non-CVD causes of mortality in this young population that is particularly vulnerable to premature death. Previous studies have often had too few deaths (4) or have not collected key risk factors at baseline (1,2). The few large cohort studies that have studied this question have produced inconsistent findings (4–6), in part because key common risk factors were not always included. Therefore, the aim of this study was to examine risk factors for all-cause mortality in a large, 7-year prospective cohort study of patients with type 1 diabetes.     

Higher Prevalence of Retinopathy in Diabetic Patients of South Asian Ethnicity Compared With White Europeans in the Community: A cross-sectional study

OBJECTIVE—The purpose of this study was to compare prevalence and risk factors for diabetic retinopathy among U.K. residents of South Asian or white European ethnicity.RESEARCH DESIGN AND METHODS—This was a community-based cross-sectional study involving 10 general practices; 1,035 patients with type 2 diabetes were studied: 421 of South Asian and 614 of white European ethnicity. Diabetic retinopathy, sight-threatening retinopathy, maculopathy, and previous laser photocoagulation therapy were assessed after grading of retinal photographs. Data were collected on risk factors including age, duration, and treatment of diabetes, blood pressures, serum total cholesterol, and A1C.RESULTS—Patients of South Asian ethnicity had significantly higher systolic (144 vs. 137 mmHg, P < 0.0001) and diastolic (84 vs. 74 mmHg, P < 0.0001) blood pressure, A1C (7.9 vs. 7.5%, P < 0.0001), and total cholesterol (4.5 vs. 4.2 mmol/l, P < 0.0001). Diabetic retinopathy was detected in 414 (40%) patients (189 South Asian [45%] versus 225 white European [37%]; P = 0.0078). Sight-threatening retinopathy was detected in 142 (14%) patients (68 South Asian [16%] versus 74 white European [12%]; P = 0.0597). After adjustment for confounders, there were significantly elevated risks of any retinopathy and maculopathy for South Asian versus white European patients.CONCLUSIONS—Patients of South Asian ethnicity had a significantly higher prevalence of diabetic retinopathy and maculopathy, with significantly elevated systolic and diastolic blood pressure, A1C, and total cholesterol; lower attained age; and younger age at diagnosis. Earlier onset of disease and higher levels of modifiable risk factors make early detection of diabetes, annual referral for retinal screening, and intensive risk factor control key elements in addressing this health inequality.Diabetes is one of the most common chronic conditions in the Western world, and its prevalence is increasing worldwide (1). Common risk factors for the development of its microvascular and macrovascular complications include duration of diabetes, poor glycemic control, elevated blood pressure, and dyslipidemia, the latter three of which are potentially amenable to therapeutic intervention (2,3). Diabetic retinopathy is the leading cause of blindness among the working age-group, the incidence of blindness is increasing rapidly, and the prevalence of visual impairment is higher in South Asians in the U.K. (4,5). There is conflicting evidence regarding the epidemiology of diabetic retinopathy in South Asians (6–9).The U.K. Prospective Diabetes Study (UKPDS) showed similar prevalences of retinopathy at diagnosis and trial entry in its South Asian, Afro-Caribbean, and white European groups (10), whereas Mather et al. (6) showed that South Asians were 1.5 times more likely to have laser treatment for diabetic retinopathy. Recent studies in the U.K. reported higher prevalences of retinopathy in South Asians (7,8).The aim of this study was to evaluate the prevalence of diabetic retinopathy and its risk factors among South Asians compared with white Europeans in a community setting in the U.K., using data from the Coventry Diabetes Retinopathy Screening service and general practitioner records.     

Weight change in diabetes and glycemic and blood pressure control

OBJECTIVE—Weight loss in type 2 diabetes is undisputedly important, and data from community settings are limited. We evaluated weight change and resulting glycemic and blood pressure control in type 2 diabetic patients at an HMO.RESEARCH DESIGN AND METHODS—Using electronic medical records, this retrospective cohort study identified 2,574 patients aged 21–75 years who received a new diagnosis of type 2 diabetes between 1997 and 2002. We estimated 3-year weight trajectories using growth curve analyses, grouped similar trajectories into four categories using cluster analysis, compared category characteristics, and predicted year-4 above-goal A1C and blood pressure by group.RESULTS—The weight-trajectory groups were defined as higher stable weight (n = 418; 16.2%), lower stable weight (n = 1,542; 59.9%), weight gain (n = 300; 11.7%), and weight loss (n = 314; 12.2%). The latter had a mean weight loss of 10.7 kg (−9.8%; P < 0.001) by 18 months, with near-complete regain by 36 months. After adjusting for age, sex, baseline control, and related medication use, those with higher stable weight, lower stable weight, or weight-gain patterns were more likely than those who lost weight to have above-goal A1C (odds ratio [OR] 1.66 [95% CI 1.12–2.47], 1.52 [1.08–2.14], and 1.77 [1.15–2.72], respectively). Those with higher stable weight or weight-gain patterns were more likely than those who lost weight to have above-goal blood pressure (1.83 [1.31–2.57] and 1.47 [1.03–2.10], respectively).CONCLUSIONS—A weight-loss pattern after new diagnosis of type 2 diabetes predicted improved glycemic and blood pressure control despite weight regain. The initial period postdiagnosis may be a critical time to apply weight-loss treatments to improve risk factor control.Almost all adults with diabetes are overweight; more than half are obese (1). Obesity is associated with worse blood glucose and other cardiovascular risk factor control (2). Results from the Look AHEAD trial show that weight loss in diabetes improves glycemic control, reduces blood pressure, and improves blood lipids (3). Observational studies also support a likely link between weight loss and reduced mortality in people with diabetes (2).Limited data describe the extent to which weight loss, as well as resulting levels of glycemic and blood pressure control, is achieved in community-living people with type 2 diabetes (4,5). Most weight information on these subjects comes from research volunteers (4,5). Prior studies of health effects of weight change have been plagued by confounding of low weight by disease burden and by difficulty separating intentional from unintentional weight loss (6,7).This study used electronic medical records data to evaluate weight trajectories in the initial years following a new type 2 diabetes diagnosis, associated demographic and comorbidity factors, and resulting glycemic and blood pressure control. The initial period after a diabetes diagnosis is of particular interest because this may be a time of heightened patient and clinician interest in patient behavior change (8).     

Sex disparities in the treatment and control of cardiovascular risk factors in type 2 diabetes

OBJECTIVE—To assess whether sex differences exist in the effective control and medication treatment intensity of cardiovascular disease (CVD) risk factors.RESEARCH DESIGN AND METHODS—We performed a cross-sectional analysis including 44,893 patients with type 2 diabetes (51% women). End points included uncontrolled CVD risk factors (LDL cholesterol ≥130 mg/dl, systolic blood pressure [SBP] ≥140 mmHg, and A1C ≥8%) and the intensity of medical management in patients with uncontrolled CVD risk factors. Multiple-adjusted odds ratios were calculated after stratification for the presence of CVD (present in 39% of the patients).RESULTS—Women with CVD were less likely to have SBP, LDL cholesterol, and A1C controlled and less likely to receive intensive lipid-lowering treatment. Women without CVD were less likely than men to have LDL cholesterol controlled with no differences in SBP or A1C control.CONCLUSIONS—Women with diabetes and CVD have poorer control of important modifiable risk factors than men and receive less intensified lipid-lowering treatment.Mortality rates from cardiovascular disease (CVD) have been declining during recent years in both men and women in the U.S. and Europe (1,2). However, in patients with diabetes, a decrease has been observed only in men (2). Furthermore, the relative risk for fatal diabetes-associated coronary heart disease is 50% higher in women than in men (3). More adverse cardiovascular risk profiles among women with diabetes has been postulated as a possible explanation, as well as potential disparities in treatment that favor men (3–5). A study from U.S. managed care health plans found poorer control of blood pressure and LDL cholesterol in female compared with male patients and suggested that these findings may contribute to the sex disparity in CVD mortality trends (6). No study in Europe has investigated sex disparities in the main cardiovascular risk factors in patients with diabetes and/or has put them into perspective with treatment intensity.     

Trends in postpartum diabetes screening and subsequent diabetes and impaired fasting glucose among women with histories of gestational diabetes mellitus: A report from the Translating Research Into Action for Diabetes (TRIAD) Study

OBJECTIVE—The purpose of this study was to examine trends in postpartum glucose screening for women with gestational diabetes mellitus (GDM), predictors of screening, trends in postpartum impaired fasting glucose (IFG) and diabetes, and diabetes and pre-diabetes detected by postpartum fasting plasma glucose (FPG) versus a 75-g oral glucose tolerance test (OGTT).RESEARCH DESIGN AND METHODS—This was a cohort study of 14,448 GDM pregnancies delivered between 1995 and 2006. Postpartum screening was defined as performance of either an FPG or OGTT at least 6 weeks after delivery and within 1 year of delivery.RESULTS—Between 1995 and 2006, the age- and race/ethnicity-adjusted proportion of women who were screened postpartum rose from 20.7% (95% CI 17.8–23.5) to 53.8% (51.3–56.3). Older age, Asian or Hispanic race/ethnicity, higher education, earlier GDM diagnosis, use of diabetes medications during pregnancy, and more provider contacts after delivery were independent predictors of postpartum screening. Obesity and higher parity were independently associated with lower screening performance. Among women who had postpartum screening, the age- and race/ethnicity-adjusted proportion of IFG did not change over time (24.2 [95% CI 20.0–27.8] in 1995–1997 to 24.3 [22.6–26.0] in 2004–2006), but the proportion of women with diabetes decreased from 6.1 (95% CI 4.2–8.1) in 1995–1997 to 3.3 (2.6–4.0) in 2004–2006. Among women who received an OGTT in 2006, 38% of the 204 women with either diabetes or pre-diabetes were identified only by the 2-h glucose measurements.CONCLUSIONS—Postpartum screening has increased over the last decade, but it is still suboptimal. Compared with FPGs alone, the 2-h values identify a higher proportion of women with diabetes or pre-diabetes amenable to intervention.Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance with onset of or first recognition during pregnancy. Postpartum diabetes screening may detect diabetes that preceded pregnancy and therefore enable early treatment of hyperglycemia, reducing the risk of adverse fetal outcomes in subsequent pregnancies (1) and maternal microvascular complications (2). Screening can also identify women who might benefit from diabetes prevention interventions (3,4).Performance rates of postpartum diabetes screening have been low (5–7), but screening performance may have changed recently. At present, only one population-based report has examined postpartum diabetes screening practices, and this report examined fasting plasma glucose (FPG) only (8). We used data from a GDM registry in a large prepaid group practice managed health care organization (the Kaiser Permanente Medical Care Program in Northern California [KPNC]) and examined 1) postpartum diabetes screening over time, 2) predictors of postpartum screening in a detailed electronic medical record, 3) trends in impaired fasting glucose (IFG) or diabetes detected with postpartum screening, and 4) the proportion of women with diabetes or pre-diabetes identified by the FPG screen versus the proportion of women with these abnormal glucose values identified by the 75-g oral glucose tolerance test (OGTT).     

Dysglycemia and a history of reproductive risk factors

OBJECTIVE—The purpose of this study was to identify reproductive risk factors associated with dysglycemia (diabetes, impaired glucose tolerance, and impaired fasting glucose) in a contemporary multiethnic population.RESEARCH DESIGN AND METHODS—We studied 14,661 women screened with an oral glucose tolerance test for the Diabetes Reduction Assessment with Ramipril and Rosiglitazone Medication (DREAM) trial. Reproductive risk factors were compared in normoglycemic and dysglycemic women.RESULTS—Dysglycemia was significantly associated with the number of children born (odds ratio 1.03 per child [95% CI 1.01–1.05]), age (1.05 per year [1.04–1.05]), non-European ancestry (1.09 [1.01–1.17]), preeclampsia/eclampsia (1.14 [1.02–1.27]), irregular periods (1.21 [1.07–1.36]), and gestational diabetes mellitus (GDM) (1.53 [1.35–1.74]). The relationship between GDM and dysglycemia did not differ across BMI tertiles (P = 0.84) nor did the relationships of other risk factors.CONCLUSIONS—Reproductive factors, particularly GDM, are associated with dysglycemia in middle-aged women from many ethnicities. Reproductive factors can be used to counsel young women about their future risk of dysglycemia, whereas in middle age they may help screen for dysglycemia.Gestational diabetes mellitus (GDM) is a well-known reproductive risk factor for subsequent type 2 diabetes (1). Other reproductive factors such as preeclampsia are associated with insulin resistance during pregnancy and may also increase the subsequent risk for diabetes. Furthermore, some (2–4) but not all (5) studies suggest that pregnancy itself is a risk factor for future type 2 diabetes. For example, a population-based study of 1,186 elderly women showed that, even after accounting for age, obesity, and family history of diabetes, parity was associated with an increased risk of type 2 diabetes, with an odds ratio (OR) of 1.16 per pregnancy (95% CI 1.04–1.20) (3). An even larger study comprising 2,310 women with type 2 diabetes reported that parity greater than six was associated with a relative risk (RR) of diabetes of 1.56 (95% CI 1.27–1.91); however, the estimate of the RR decreased to 1.19 (0.97–1.48) after adjustment for current age (2). The applicability of these results is limited by the homogeneity of the population (registered nurses with relatively high socioeconomic status and 98% Caucasian) and the use of the older fasting plasma glucose cutoff for diabetes of >7.8 mmol/l (>140 mg/dl) rather than the current, more sensitive value of 7.0 mmol/l (126 mg/dl) (6).The prevalence of dysglycemia (type 2 diabetes, impaired glucose tolerance [IGT], and impaired fasting glucose [IFG]) is increasing; however, reproductive risk factors are often underrecognized. In particular, their association with the more recently recognized forms of glucose dysregulation, IGT and IFG, have not yet been well studied. The detection of dysglycemia could be improved if risk factors were better known. Moreover, if reproductive factors such as parity and preeclampsia are risk factors for dysglycemia, they could be used to refine screening approaches. The goal of this research was to identify reproductive risk factors for dysglycemia in a contemporary, multiethnic group of women.     

Dietary patterns and risk of incident type 2 diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA)

OBJECTIVE—We characterized dietary patterns and their relation to incident type 2 diabetes in 5,011 participants from the Multi-Ethnic Study of Atherosclerosis (MESA).RESEARCH DESIGN AND METHODS—White, black, Hispanic, and Chinese adults, aged 45–84 years and free of cardiovascular disease and diabetes, completed food frequency questionnaires at baseline (2000–2002). Incident type 2 diabetes was defined at three follow-up exams (2002–2003, 2004–2005, and 2005–2007) as fasting glucose >126 mg/dl, self-reported type 2 diabetes, or use of diabetes medication. Two types of dietary patterns were studied: four empirically derived (principal components analysis) and one author-defined (low-risk food pattern) as the weighted sum of whole grains, vegetables, nuts/seeds, low-fat dairy, coffee (positively weighted), red meat, processed meat, high-fat dairy, and soda (negatively weighted).RESULTS—The empirically derived dietary pattern characterized by high intake of tomatoes, beans, refined grains, high-fat dairy, and red meat was associated with an 18% greater risk (hazard ratio per 1-score SD 1.18 [95% CI 1.06–1.32]; P_trend = 0.004), whereas the empirically derived dietary pattern characterized by high intake of whole grains, fruit, nuts/seeds, green leafy vegetables, and low-fat dairy was associated with a 15% lower diabetes risk (0.85 [0.76–0.95]; P_trend = 0.005). The low-risk food pattern was also inversely associated with diabetes risk (0.87 [0.81–0.99]; P_trend = 0.04). Individual component food groups were not independently associated with diabetes risk. Associations were not modified by sex or race/ethnicity.CONCLUSIONS—Multiple food groups collectively influence type 2 diabetes risk beyond that of the individual food groups themselves.Type 2 diabetes and obesity have reached epidemic proportions in the U.S. and the world. In addition to the role diet plays in preventing obesity and, consequently, type 2 diabetes, diet may also reduce risk of type 2 diabetes independent of changes in body weight. Whole grains (1), nuts/seeds (2), coffee (3), low-fat dairy (4,5), and vegetables (6,7) have been inversely associated with incident type 2 diabetes or related metabolic traits independent of differences in body weight or other measures of adiposity, whereas sugar-sweetened beverages (8,9), red meat (10), processed meats (11), and white potatoes (fried or baked/boiled) (12) have been positively associated.In practice, each nutrient or food is part of a larger pattern consisting of many nutrients and foods, and, thus, characterization of multiple, concurrent dietary exposures has particular relevance to health. Using data-driven techniques, such as principal components analysis (PCA), several epidemiological studies have evaluated associations between dietary patterns and type 2 diabetes (10,11,13–15). Generally, studies show that dietary patterns characterized by high whole grain, fruit/vegetable, and low-fat dairy intake are inversely associated with type 2 diabetes risk. Analogously, dietary patterns characterized by high intake of red or processed meats, refined grains, fried foods, and foods containing high amounts of added sugars are associated with greater type 2 diabetes risk. Studies have been conducted in relatively homogenous populations (predominantly white cohorts) (10,11,13–15). Validation of these findings in racially/ethnically diverse samples is needed.Empirical methods such as PCA do not necessarily maximize the disease-predictive value of each dietary pattern; rather, such methods maximize the amount of variation in dietary intake explained by each dietary pattern. Variation in dietary intake comprises dietary behaviors, taste, and convenience. For this reason, combinations of foods other than those identified by PCA might be more predictive of incident disease. Studies have shown that individual food groups, such as those listed above, are independently associated with incident type 2 diabetes. However, the collective contribution of these foods to type 2 diabetes risk has not been characterized.Using data from the Multi-Ethnic Study of Atherosclerosis (MESA), we evaluated the relationship between type 2 diabetes risk and the following two trends: 1) PCA-derived dietary patterns and 2) a low-risk food pattern score based on the intake of foods previously associated with risk of type 2 diabetes (whole grains, vegetables, low-fat dairy foods, nuts/seeds, and coffee [positively weighted] and red meat, processed meat, high-fat dairy foods, white potatoes, and nondiet soda [negatively weighted]).     

Leptin Predicts Diabetes but Not Cardiovascular Disease: Results from a large prospective study in an elderly population

OBJECTIVE—To clarify the association of circulating levels of leptin with risk for cardiovascular disease (CVD) events and new-onset diabetes in men and women.RESEARCH DESIGN AND METHODS—We related baseline leptin levels to CVD events (n = 864) and incident diabetes (n = 289) in an elderly population (n = 5,672) over 3.2 years of follow-up.RESULTS—In treatment-, age-, and country-adjusted models, leptin was not associated with risk of CVD in men (hazard ratio 1.02 [95% CI 0.90–1.16] per unit log-leptin increase) or women (1.05 [0.91–1.20]) but was associated with risk of diabetes in men (2.75 [2.14–3.52]) and women (1.54 [1.22–1.94]). After adjusting for classic risk factors and BMI, C-reactive protein, and glucose, the diabetes association retained significance in men (1.85 [1.30–2.63]) but not in women (0.89 [0.64–1.26]).CONCLUSIONS—Leptin, similar to other markers of adiposity in general, is more strongly related to risk of diabetes than CVD in the elderly.Leptin is a pleiotropic adipokine, and circulating levels correlate with markers of body fat mass (1). Obesity is a known risk factor for the development of both cardiovascular disease (CVD) and type 2 diabetes, and leptin is a candidate mediator of these increased risks. Hyperleptinemia may promote atherosclerosis (2), and dysregulation of leptin signaling in obese individuals results in reduced fatty acid oxidation and glucose uptake (3).There is evidence for (4–6) and against (7–10) leptin being a prospective risk marker for CVD, whereas there is evidence that leptin predicts diabetes risk independently of other confounders only in men (11–13). We aimed to clarify these risk associations by simultaneous comparison of end points in both sexes individually in a single study.     

Impaired chronotropic response to exercise stress testing in patients with diabetes predicts future cardiovascular events

OBJECTIVES— To assess the association between impaired chronotropic response (CR) and adverse events among patients with diabetes referred for exercise treadmill testing (ETT).RESEARCH DESIGN AND METHODS— Impaired CR was defined as achievement of <80% of a patient''s heart rate reserve. We used multivariable Cox proportional hazards regression to assess the independent association between impaired CR and adverse outcomes adjusting for demographics, comorbidities, and treadmill variables including the Duke Treadmill score.RESULTS— Of 1,341 patients with diabetes, 35.7% (n = 479) demonstrated impaired CR during ETT. Patients with impaired CR were at increased risk of all-cause mortality, myocardial infarction, or coronary revascularization procedures. In multivariable analyses, impaired CR remained significantly associated with adverse outcomes (hazard ratio 1.53 [95% CI 1.10–2.14]).CONCLUSIONS— Among patients with diabetes, impaired CR is common during ETT and is associated with adverse outcomes. Impaired CR can be used as another noninvasive tool to risk-stratify patients with diabetes following ETT.Impaired chronotropic response (CR) is defined as inability of the heart rate to increase normally with exercise and may be related to alterations in sympathetic and parasympathetic tone, as well as autonomic dysfunction (1). Impaired CR during exercise treadmill testing (ETT) is associated with increased risk of cardiac events and all-cause mortality (2–4). Patients with diabetes have a higher incidence of autonomic dysfunction, and therefore impaired CR during ETT may identify patients with diabetes at risk for adverse outcomes (1). However, prior studies assessing the prognostic import of impaired CR have not specifically focused on this subgroup or have only included small numbers of patients with diabetes or the association between impaired CR and adverse outcomes has been inconclusive among patients with diabetes (1,3,5). Therefore, the objective of this study was to assess the association between impaired CR and adverse events, including all-cause mortality, myocardial infarction, and coronary revascularization procedures among patients with diabetes referred for ETT in routine clinical practice.     

Risks of nontraumatic lower-extremity amputations in patients with type 1 diabetes: a population-based cohort study in Sweden

OBJECTIVE—The purpose of this study was to estimate the risks of nontraumatic lower-extremity amputations (LEAs) in patients with type 1 diabetes.RESEARCH DESIGN AND METHODS—We identified 31,354 patients with type 1 diabetes (15,001 women and 16,353 men) in the Swedish Inpatient Register between 1975 and 2004. The incidence of nontraumatic LEAs was followed up until 31 December 2004 by cross-linkage in the Inpatient Register and linkage to the Death and Migration registers. Poisson regression modeling was used to compare the risks of nontraumatic LEAs during different calendar periods of follow-up, with adjustment for both sex and attained age at follow-up. Standardized incidence ratios (SIRs) were used to estimate the relative risks (RRs) with the age-, sex-, and calendar period–matched general Swedish population as reference. The cumulative probability of nontraumatic LEAs was calculated by the Kaplan-Meier method.RESULTS—In total, 465 patients with type 1 diabetes underwent nontraumatic LEAs. The risk was lower during the most recent calendar period (2000–2004) than during the period before 2000 (RR 0.6 [95% CI 0.5–0.8]). However, even in this most recent period, the risk for nontraumatic LEAs among these relatively young patients was 86-fold higher than that in the matched general population (SIR 85.8 [72.9–100.3]). By age 65 years, the cumulative probability of having a nontraumatic LEA was 11.0% for women with type 1 diabetes and 20.7% for men with type 1 diabetes.CONCLUSIONS—Although the risks appeared to have declined in recent years, patients with type 1 diabetes still have a very high risk for nontraumatic LEAs.Ulceration of the foot is the most common first indicator of impending nontraumatic lower-extremity amputations (LEAs) related to diabetes, and it has been estimated worldwide that one lower limb is amputated every 30 s as a consequence of this condition. Of all nontraumatic LEAs, 50–70% are associated with diabetes (1). Diabetic foot ulceration involves a complex underlying pathophysiology and a multifactorial approach to care, including preventive foot care, aggressive management of acute foot ulceration, control of infections, and early recognition of vascular disease, which are all of major importance in this context (2,3). In addition to reducing quality of life and enhancing morbidity, disability, and premature mortality (4,5), diabetic foot complications are a considerable financial burden on society and individual patients (6), accounting for ∼20% of the total expenditure on health care for patients with diabetes (1).The incidence of nontraumatic LEAs as a consequence of diabetes is considered to be a key indicator of the quality of foot care for such patients (7). In 1989, the World Health Organization and International Diabetes Federation initiated a joint program called the Saint Vincent Declaration for improving the care of patients with diabetes (8). The goals set forth included a >50% reduction in major nontraumatic LEAs caused by diabetes. It is unclear whether this goal has been attained in the case of type 1 diabetes, as most relevant epidemiological studies reported have been concerned with patients with type 2 diabetes or a mixture of type 1 and type 2 diabetic patients (9–11). Therefore, the aim of this register-based study involving a large cohort was to obtain an estimate of the risk of nontraumatic LEAs in patients with type 1 diabetes.     

Racial/Ethnic Differences in Concerns About Current and Future Medications Among Patients With Type 2 Diabetes

OBJECTIVE—To evaluate ethnic differences in medication concerns (e.g., side effects and costs) that may contribute to ethnic differences in the adoption of and adherence to type 2 diabetes treatments.RESEARCH DESIGN AND METHODS—We conducted face-to-face interviews from May 2004 to May 2006 with type 2 diabetic patients ≥18 years of age (N = 676; 25% Latino, 34% non-Hispanic Caucasian, and 41% non-Hispanic African American) attending Chicago-area clinics. Primary outcomes of interest were concerns regarding medications and willingness to take additional medications.RESULTS—Latinos and African Americans had higher A1C levels than Caucasians (7.69 and 7.54% vs. 7.18%, respectively; P < 0.01). Latinos and African Americans were more likely than Caucasians to worry about drug side effects (66 and 49% vs. 39%, respectively) and medication dependency (65 and 52% vs. 39%, respectively; both P < 0.01). Ethnic minorities were also more likely to report reluctance to adding medications to their regimen (Latino 12%, African American 18%, and Caucasian 7%; P < 0.01). In analyses adjusted for demographics, income, education, and diabetes duration, current report of pain/discomfort with pills (odds ratio 2.43 [95% CI 1.39–4.27]), concern regarding disruption of daily routine (1.97 [1.14–3.42]), and African American ethnicity (2.48 [1.32–4.69]) emerged as major predictors of expressed reluctance to adding medications.CONCLUSIONS—Latinos and African Americans had significantly more concerns regarding the quality-of-life effects of diabetes-related medications than Caucasians. Whether these medication concerns contribute significantly to differences in treatment adoption and disparities in care deserves further exploration.Type 2 diabetic patients of racial/ethnic minorities experience significantly higher rates of diabetes-related complications than non-Hispanic Caucasians. In population-based studies, non-Hispanic African Americans have rates of renal disease, blindness, amputations, and amputation-related mortality two to four times greater than those of Caucasians (1–3). Similarly, Latinos have higher rates of renal disease and retinopathy than Caucasians (1,2,4,5). African American patients have age-adjusted diabetes mortality rates that are approximately twice those of Caucasians (6). The elimination of such health disparities is a major goal of the U.S. preventive health agenda (7).Efforts to reduce the burden of diabetes complications have focused on improving the delivery of comprehensive diabetes care while simultaneously addressing control of blood glucose, blood pressure, and cholesterol. Modern diabetes care requires greater use of medications and a standard form of polypharmacy (8–10). Whereas there is some evidence that more patients with diabetes are adopting comprehensive diabetes care (11), many recent studies continue to show that large proportions of patients with diabetes continue to have poor glycemic (20%), blood pressure (33%), and cholesterol (40%) control (12). Patients’ concerns regarding the burdens of life with medications may be key factors to determining patients’ willingness or unwillingness to adopt multiple medications; an unwillingness to adopt medications may be grounded in legitimate concerns. Patients’ level of adoption of multiple medications may, in turn, influence the intensity of risk factor control for the general population and for racial/ethnic minorities. In support of this conjecture, a recent study has reported that racial/ethnic differences in medication adherence are among the most significant independent predictors of disparities in glycemic control (13).Whereas patient concerns regarding the burdens of medications may be a key determinant of both the intensity of diabetes care for the general population and disparities in care, few studies have directly examined and quantified patient concerns regarding the burdens of daily diabetes medications across racial/ethnic groups (14). These concerns may systematically differ by race/ethnicity and may be associated with differential willingness to adopt more medications. We set out to determine whether there are racial/ethnic differences in medication concerns and the willingness to adopt more medications among a sample of adults with type 2 diabetes living in the Chicago area.     

Weight-loss practices and weight-related issues among youth with type 1 or type 2 diabetes

OBJECTIVE—The purpose of this study was to describe the weight-loss practices and weight-related issues reported by youth with diabetes, according to sex and diabetes type.RESEARCH DESIGN AND METHODS—A total of 1,742 female and 1,615 male youth aged 10–21 years with type 1 or type 2 diabetes completed a SEARCH for Diabetes in Youth study visit during which height, weight, and A1C were measured. A survey assessed weight-related issues and weight-loss practices.RESULTS—Although more common in youth with type 2 diabetes, youth with type 1 diabetes also reported weight-related concerns and had elevated BMI. Among youth who had ever tried to lose weight (n = 1,646), healthy weight-loss practices (diet [76.5%] and exercise [94.8%]) were the most common, whereas unhealthy practices (fasting [8.6%], using diet aids [7.5%], vomiting or laxative use [2.3%], and skipping insulin doses [4.2%]) were less common. In sex-specific multivariable models including age, race/ethnicity, diabetes type, BMI category, and glycemic control, obese females and overweight/obese males were more likely to report ever practicing any unhealthy weight-loss practice than normal-weight youth. These practices were associated with poor glycemic control for female but not male subjects. All unhealthy weight-loss practices except fasting were more common in female than in male subjects. Dieting, fasting, and using diet aids were all more common in youth with type 2 diabetes than in those with type 1 diabetes.CONCLUSIONS—Given the prevalence of overweight and obesity among youth with type 1 or type 2 diabetes, health care professionals caring for youth with diabetes need to pay particular attention to identifying youth, particularly females, with unhealthy weight-loss practices.Diabetes is one of the three most prevalent chronic diseases of youth (1), with the majority of affected youth having type 1 diabetes (2). However, type 2 diabetes is being diagnosed more frequently in youth than has been reported in previous decades (2–4). Although youth with type 2 diabetes are likely to be overweight or obese, the increase in overweight in the U.S. population is mirrored among youth with type 1 diabetes (5,6). Strategies used to lose or manage weight include those that are healthy, such as regular physical activity and consuming a healthy diet, as well as those that are unhealthy, such as using over-the-counter diet aids without physician''s advice, fasting, taking laxatives or diuretics, and vomiting. In 2005, 12.3% of 9th to 12th graders went without eating for at least 24 hours, 6.3% used diet pills, powders, or liquids, and 4.5% vomited or took laxatives to maintain or lose weight (7). Females were significantly more likely than males to use these unhealthy strategies; some racial/ethnic differences were observed.Certain features of diabetes and its management, including weight gain after the initiation of insulin treatment, dietary restraint, and the knowledge that withholding insulin can cause weight loss, may trigger eating disturbances in youth with type 1 diabetes (8). Eating disorders have been associated with poor metabolic control and microvascular complications in type 1 diabetic youth (9–12). There is limited information about weight-related concerns among youth with type 2 diabetes. The American Diabetes Association recommends that youth with type 2 diabetes implement lifestyle modifications to reduce their intake of high-fat, high-energy foods and to increase physical activity to optimize glycemic control as well as their cardiovascular risk profile, including their lipid levels and blood pressure (13). At the same time, medical nutrition therapy must take in to account the nutritional needs required to support normal growth and development during childhood and adolescence (13,14). In this article, we describe the approaches to healthy and unhealthy weight-loss practices reported by youth with type 1 or type 2 diabetes by sex. In addition, we explore the associations between any unhealthy weight-loss practice, body weight perception, weight management goal, and worry about weight and glycemic control among youth with type 1 or type 2 diabetes by sex.     

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).     

Dietary patterns, insulin resistance, and incidence of type 2 diabetes in the Whitehall II Study

OBJECTIVE—The aim of this study was to identify a dietary pattern associated with insulin resistance and investigate whether this pattern was prospectively associated with type 2 diabetes.RESEARCH DESIGN AND METHODS—Analysis was based on 7,339 participants of the Whitehall II study. Dietary intake was measured using a 127-item food frequency questionnaire. We used the reduced rank regression method to determine dietary patterns using the homeostasis model assessment of insulin resistance as the intermediate or response variable. The association between the dietary pattern identified and incidence of type 2 diabetes was investigated using Cox proportional hazard regression models.RESULTS—We identified a dietary pattern characterized by high consumption of low-calorie/diet soft drinks, onions, sugar-sweetened beverages, burgers and sausages, crisps and other snacks, and white bread and low consumption of medium-/high-fiber breakfast cereals, jam, French dressing/vinaigrette, and wholemeal bread. Higher dietary pattern scores were associated with increased risk of type 2 diabetes (hazard ratio for top quartile 2.95 [95% CI 2.19–3.97]; adjusted for age, sex, and energy misreporting). This relationship was attenuated after adjustment for ethnicity, employment grade, health behaviors (smoking, alcohol use, and physical activity) but remained significant after further adjustment for blood pressure and BMI (1.51 [1.10–2.09]).CONCLUSIONS—A dietary pattern associated with insulin resistance predicts type 2 diabetes risk after adjustment for a range of confounders. This study adds to the evidence that dietary patterns are an important risk factor for type 2 diabetes.The worldwide prevalence of type 2 diabetes is alarmingly high (1). Diabetes is an important cause of morbidity and a major risk factor for cardiovascular disease (2). Dietary intake is a potentially modifiable risk factor (2), and although there is convincing evidence for the role of excess calorie intake in the development of type 2 diabetes, the evidence surrounding other diet-related risk factors is far less complete or convincing (3). Further research is required to identify optimal eating patterns for the prevention of type 2 diabetes and provide the evidence base for dietary targets.In much of the work surrounding diet and chronic disease, a single nutrient approach has been adopted. Increasingly, dietary patterns are thought to be important determinants of chronic disease (4). A dietary patterns approach recognizes that foods are consumed in many complex combinations and that nutrients may have interactive and synergistic effects (4).Approaches to studying dietary patterns fall into two categories, using either dietary scores determined by a priori dietary guidelines or multivariate statistical techniques (4). To date, multivariate statistical approaches have tended to use factor and cluster analysis techniques (4). However, a new approach to dietary pattern analysis has emerged that combines multivariate approaches with existing knowledge of diet-disease relationships (5). In reduced rank regression (RRR) analysis, variations in food intake are used to predict intermediate outcomes such as nutrient intakes, biomarkers of intakes, or biomarkers of the disease process and subsequently relationships between the identified dietary patterns and disease are investigated. This approach has been used to study obesity (6), diabetes (5,7,8), cardiovascular disease (9,10), and all-cause mortality (11). Previous studies of type 2 diabetes and dietary patterns using RRR relied on self-report of diabetes status without an oral glucose tolerance test (OGTT) to identify incident disease (5,7,8).The aim of this study was to identify a dietary pattern using RRR that is associated with insulin resistance, a phenotype closely associated with development of type 2 diabetes, and, subsequently, to investigate the prospective association between the dietary pattern and disease.