母亲妊娠期糖尿病对胎儿结局影响的研究进展北大核心CSCD

妊娠期糖尿病(GDM)是妊娠期最常见的代谢紊乱性疾病,严重影响胎儿的正常发育。妊娠期血糖控制情况不仅与早产、巨大儿、低血糖、新生儿呼吸窘迫综合征、电解质紊乱、心脏发育畸形和肠道菌群紊乱等近期不良结局有关,而且与持续的糖耐量受损、肥胖、代谢综合征、神经精神疾病及眼科疾病等远期结局相关。正确认识GDM对新生儿近期与远期造成的不良影响及其相关机制,及时采取相应的防治措施,可显著改善妊娠结局。本文将对此作一综述。     

Infants of diabetic mothers

Advances in the management of the mother with diabetes have reduced the rate of morbidity and mortality for her infant. Aggressive control of maternal glycemic status is warranted, because most morbidities are epidemiologically and pathophysiologically closely linked to fetal hyperglycemia and hyperinsulinemia. The burgeoning public health problem of overweight and obesity in children will likely result in an increased incidence of metabolic syndrome X, characterized by insulin resistance and type II diabetes in adulthood. An early manifestation of this may be glucose intolerance during pregnancy in overweight women without diabetes. Clinicians must continue to have a high degree of suspicion for the diagnosis of diabetes during gestation and screen offspring of women with gestational diabetes for neonatal sequelae.     

Long-term effects of diabetes during pregnancy on the offspring

Background: Many epidemiological and experimental studies have proven that some adult diseases might have their origin in fetal life. It has been also hypothesized that intra-uterine environment in pregnancy complicated with diabetes might influence the development of obesity, type 2 diabetes, and cardiovascular diseases in the offspring.
Objectives: To assess glucose metabolism, insulin secretion, and prevalence of obesity in the offspring of mothers with pregestational diabetes mellitus (PGDM) and gestational diabetes mellitus (GDM) and to evaluate the relationship between maternal metabolic control during pregnancy and metabolic disturbances in children.
Subjects: Children of mothers with PGDM (n = 43) and GDM (n = 34) were examined at 4–9 yr of age and compared with the control group (n = 108; metabolic parameters available for n = 29).
Methods: The incidence of overweight and obesity, impaired glucose tolerance, and insulin resistance were analyzed based on anthropometric and biochemical measurements. Statistical analysis was performed with statistica package.
Results: In children of GDM mothers, body mass index z-score (0.81 ± 1.01 vs. −0.04 ± 1.42 PGDM vs. 0.07 ± 1.28 control group) and insulin resistance indices (homeostasis model assessment index – insulin resistance 1.112 vs. 0.943 PGDM vs. 0.749 control group) were significantly higher than in other groups. Obesity and insulin resistance were also most frequent in GDM group [not significant (NS)]. In addition, we observed the relationship between maternal hemoglobin A1c and mean glycemia in perinatal period and insulin resistance in children. There was not such correlation for the class of maternal diabetes.
Conclusion: Children born to mothers with gestational diabetes seem to be at risk for obesity and metabolic disturbances.     

Accelerated starvation in pregnancy: implications for dietary treatment of obesity and gestational diabetes mellitus

The biological significance of ketonemia of brief duration and moderate proportions during pregnancy remains uncertain. Thus, controversy persists about whether caloric restriction for obese women during pregnancy, particularly when the obesity is complicated by gestational diabetes mellitus (GDM), constitutes appropriate therapy. We have demonstrated, in a rigorously controlled setting using a Clinical Research Center, that all of the features of 'accelerated starvation' become manifest after 14 h and before 18 h of dietary deprivation. Women with GDM exhibit the same capacity for early 'accelerated starvation' as in normal pregnancy; thus, their insulin deficiency and insulin resistance do not appear to be sufficient to render them increasedly at risk for uncontrolled catabolism. Some cautious exploration of the use of hypocaloric diets as a therapeutic approach to the metabolic disturbances of GDM may be justified.     

Psychomotor development in the children of mothers with type 1 diabetes mellitus or gestational diabetes mellitus

The purpose of this study was to examine psychomotor development in children born to mothers with type 1 diabetes mellitus (DM1) or gestational diabetes mellitus (GDM). The influence of metabolic control in pregnant diabetic mothers and complications during labor on their children's psychological and physical development was evaluated. The analysis included 59 children, 20 of mothers with GDM, 19 of mothers with DM1, and 20 children of healthy mothers. Clinical observations and medical history were recorded and children were assessed using the Brunet-Lezine Psychomotor Development Scale. Abnormalities were found more often in the children of mothers with DM1 whose illness was insufficiently controlled during pregnancy and of mothers with serious hypoglycemia while pregnant. Speech, eye-movement coordination and social aspects were affected.     

早期营养程序化与远期肥胖

流行病学研究表明,肥胖与众多代谢疾病如2型糖尿病、高血脂、高血压等之间存在密切关系,生命早期的营养可以对机体造成程序化的影响,机体对母亲妊娠期及哺乳期不良营养刺激可以通过整体、细胞、分子水平做出适应性反应.这些反应将持续改变机体的生理和代谢,进而增加肥胖和代谢相关疾病的风险.     

Early life programming and metabolic syndrome

Metabolic syndrome (MS) has reached epidemic proportions worldwide among children. Early life “programming” is now thought to be important in the etiology of obesity, type 2 diabetes, cardiovascular disease and MS. Nutritional imbalance and exposures to endocrine disruptor chemicals during development can increase risk for MS later in life. Epigenetic marks may be reprogrammed in response to both stochastic and environmental stimuli, such as changes in diet and the in utero environment, therefore, determination of targets for early life effects on epigenetic gene regulation provides insight into the molecular mechanisms involved in the epigenetic transgenerational inheritance of a variety of adult onset disease phenotypes. The perinatal period is a crucial time of growth, development and physiological changes in mother and child, which provides a window of opportunity for early intervention that may induce beneficial physiological alternations.     

The management of type 2 diabetes in children and adolescents

The medical community faces an emerging epidemic of type 2 diabetes (T2DM) in children and adolescents with a disproportionate increase among certain ethnic groups. T2DM represents one arm of the metabolic syndrome and parallels an increasing prevalence of obesity. The metabolic syndrome includes insulin resistance, hyperlipidemia, and hypertension with a consequent risk of early cardiovascular disease. Thus, treatment of T2DM and the metabolic syndrome pose a challenge for pediatric endocrinologists and represent an enormous public health issue. This review presents information about the treatment of childhood T2DM.     

母孕期肥胖对胎儿-新生儿的影响及管理

肥胖已成为21世纪影响人类健康的最大问题之一.孕妇的肥胖对其子代会产生明显的不良影响.肥胖孕妇的死产和胎儿先天畸形发生率明显增高,剖宫分娩尤其是急诊剖宫产率明显增加.肥胖母亲自身的代谢和营养状况会对子宫内环境产生影响,使胎儿的基因发生表观遗传学的改变,从而对子代产生长期的影响,到成年时出现肥胖、心血管疾病、2型糖尿病等.因此,减少孕龄妇女的肥胖或控制孕期体重过度增加,将大幅减少肥胖对胎儿的影响,减少成年时肥胖、糖尿病、心血管疾病和代谢综合征的发生.     

The management of type 2 diabetes mellitus in children and adolescents

The medical community faces an emerging epidemic of type 2 diabetes mellitus (DM2) in children and adolescents with a disproportionate increase among certain ethnic groups. DM2 represents one arm of the metabolic syndrome and parallels an increasing prevalence of obesity. The metabolic syndrome includes insulin resistance, hyperlipidemia, and hypertension with a consequent risk of early cardiovascular disease. Thus, treatment of DM2 and the metabolic syndrome poses a challenge for pediatric endocrinologists and represents a huge public health issue. This review presents information about treatment of childhood DM2 with emphasis on indications for the use of insulin in management and normalization of blood glucose.     

Effect of a low glycaemic index diet in gestational diabetes mellitus on post‐natal outcomes after 3 months of birth: a pilot follow‐up study

A low glycaemic index (LGI) diet during pregnancy complicated by gestational diabetes mellitus (GDM) may offer benefits to the mother and infant pair beyond those during pregnancy. We aimed to investigate the effect of an LGI diet during pregnancy complicated with GDM on early post‐natal outcomes. Fifty‐eight women (age: 23–41 years; mean ± SD pre‐pregnancy body mass index: 24.5 ± 5.6 kg m^?2) who had GDM and followed either an LGI diet (n = 33) or a conventional high‐fibre diet (HF; n = 25) during pregnancy had a 75‐g oral glucose tolerance test and blood lipid tests at 3 months post‐partum. Anthropometric assessments were conducted for 55 mother–infant pairs. The glycaemic index of the antenatal diets differed modestly (mean ± SD: 46.8 ± 5.4 vs. 52.4 ± 4.4; P < 0.001), but there were no significant differences in any of the post‐natal outcomes. In conclusion, an LGI diet during pregnancy complicated by GDM has outcomes similar to those of a conventional healthy diet. Adequately powered studies should explore the potential beneficial effects of LGI diet on risk factors for chronic disease.     

Diabetic patient and reproduction

Current views and opinions on pregnancy in diabetic mothers are presented. Special attention is paid to carbohydrate metabolism, pregestational diabetes mellitus (PGDM), gestational diabetes mellitus (GDM) and unclear heterogenous etiology of gestational diabetes mellitus (GDM). Suggestions for identification, diagnosis and treatment of GDM with an emphasis on early screening strategy are given. Obstetrical management and possible perinatal complications are discussed.     

IAP National Task Force for Childhood Prevention of Adult Diseases: insulin resistance and Type 2 diabetes mellitus in childhood

Type 2 diabetes mellitus (DM) has traditionally been considered a disease of adults. However, in the last 2 decades, it is increasingly being reported in children and adolescents. Obesity is a strong correlate, and the increasing prevalence of obesity and poor physical activity is precipitating type 2 DM at younger ages in the ethnic groups at risk.Indians and other South Asians are among the ethnic groups particularly prone to insulin resistance and type 2 DM, the other racial groups being some American Indian tribes like the Pima Indians, Mexican Americans,Pacific Islanders and African Americans,among others. The WHO has predicted that India will have the greatest number of diabetic individuals in the world by the year 2025.Type 2 DM starting during adolescence puts the individual at risk for major morbidity and even mortality right during the productive years of life. The microvascular complications of DM (nephropathy, retinopathy, neuropathy) are brought on at an early age. In addition, type 2 DM and obesity are two components of a metabolic syndrome of insulin resistance, the other features of which include hypertension, dyslipidemia and hypercoagulability of blood. All these conditions together increase the risk for cardiovascular and cerebrovascular mortality and morbidity (i.e., myocardial infarction and stroke). The resulting economic burden will be enormous.Type 2 DM and the insulin resistance syndrome are to a large extent preventable.Adoption of a healthy eating and physical activity pattern has resulted in decreasing the development of DM in a few recent studies from various parts of the world. A concerted,multi-pronged effort is needed, involving the general public, pediatricians and general physicians, teachers and schools, the media,the government and professional medical bodies, to generate a momentum towards the goal of prevention of type 2 DM and the insulin resistance syndrome in the young population of India.     

Maternal type 1 and gestational diabetes: postnatal differences in insulin secretion in offspring at preschool age

Background: It is well known that children born to mothers with diabetes in pregnancy are more likely to develop metabolic abnormalities in later life. Most prior studies have not differentiated between offspring of mothers with type 1 diabetes (T1DM) and gestational diabetes (GDM) or lack a control group of non‐exposed offspring. Subjects: Offspring of T1DM (n = 16), GDM (n = 22) and mothers without diabetes (n = 25) born at Oulu University Hospital. Aim: To assess insulin secretion and insulin resistance in the offspring of T1DM and GDM at preschool age in comparison with offspring of non‐diabetic mothers. Methods: Anthropometric measurements and intravenous glucose tolerance testing were performed. First‐phase insulin response (FPIR) and homoeostasis model assessment (HOMA) values were calculated. Pregnancy and birth data were analysed in relation to later metabolic parameters in all three groups using one‐way analysis of variance (anova ) and analysis of covariance (ancova ). Results: At a mean age of 4.9 yr, offspring of T1DM had increased fasting serum insulin concentrations (p = 0.044), FPIR (p = 0.034) and HOMA‐B values (p = 0.008) compared with offspring of GDM or with offspring of healthy controls (statistically non‐significant). The GDM gained least weight during pregnancy, and when adjusted for maternal weight gain during pregnancy, there were no statistically significant differences between study groups. Conclusions: Prenatal exposures to maternal type 1 and gestational diabetes may have different effects on postnatal glucose metabolism in the offspring assessed at a mean age close to 5 yr. Maternal weight gain in pregnancy may affect the postnatal glucose metabolism in the offspring.     

Obesity in pregnancy: implications for the mother and lifelong health of the child. A consensus statement

Obesity among pregnant women is becoming one of the most important women's health issues. Obesity is associated with increased risk of almost all pregnancy complications: gestational hypertension, preeclampsia, gestational diabetes mellitus, delivery of large-for-GA infants, and higher incidence of congenital defects all occur more frequently than in women with a normal BMI. Evidence shows that a child of an obese mother may suffer from exposure to a suboptimal in utero environment and that early life adversities may extend into adulthood. In September 2009, ILSI Europe convened a workshop with multidisciplinary expertise to review practices and science base of health and nutrition of obese pregnant women, with focus on the long-term health of the child. The consensus viewpoint of the workshop identified gaps and gave recommendations for future research on gestational weight gain, gestational diabetes, and research methodologies. The evidence available on short- and long-term health impact for mother and child currently favors actions directed at controlling prepregnancy weight and preventing obesity in women of reproductive ages. More randomized controlled trials are needed to evaluate the effects of nutritional and behavioral interventions in pregnancy outcomes. Moreover, suggestions that maternal obesity may transfer obesity risk to child through non-Mendelian (e.g. epigenetic) mechanisms require more long-term investigation.     

Nutritional Management of the overweight child with type 2 diabetes

In light of the strong association between excess weight and type 2 diabetes, the nutritional management of the child with type 2 diabetes often focuses on changing dietary and physical activity habits to normalize weight, instill long-term healthy habits, and provide glycemic control. A multidisciplinary approach to the treatment of childhood obesity should include the child's family and caregivers to be most effective. Weight goals in children should be based on the age of the child, the extent of overweight, and the presence of complications. Likewise, physical activity is an important component of treatment and should be titrated to the child's age, ability and overweight status. Efforts to avoid the development of obesity, and potentially type 2 diabetes, should be started early in the child's life. Education and fostering a healthy lifestyle during childhood is the best defense to slow down or reverse the obesity epidemic in our society that is now affecting even the youngest of children, setting them up for potentially life-threatening diseases in the future.     

Aerobic fitness, fatness and the metabolic syndrome in children and adolescents

The paediatric obesity epidemic is well documented. Recently, there has also been the emergence of type 2 diabetes and the metabolic syndrome (MetS) among children and adolescents. Although it is well known that obesity is linked to the metabolic syndrome in youth, the role of physical activity and fitness on the metabolic syndrome is unclear. The purpose of this review was to examine the concepts of and associations between fitness, fatness and the MetS in children and adolescents. In general, the association between fatness and the MetS (or components of the MetS) is stronger than those for fitness. Furthermore, the correlation between fatness and the MetS remains significant after controlling for fitness, whereas the correlation between fitness and MetS does not remain significant after controlling for fatness. When subjects are cross-tabulated into categories (fat-fit, etc.), there is good evidence that fitness attenuates the MetS score among fat children and adolescents. The reasons for these observations possibly involve genetics, adipocytokines and mitochondrial function. Further study is needed to understand the role of physical activity and other environmental factors on this phenomena. In addition, longitudinal studies of the fat-fit phenotype are required and should include measurements of the hormonal mileau, adipokines and the oxidative capacity of skeletal muscle during childhood and adolescence.     

Beta Testing of a Gestational Diabetes Risk Reduction Intervention for American Indian and Alaska Native Teens

IntroductionAmerican Indian and Alaska Native (AIAN) girls have double the risk of obesity, pregnancy, and gestational diabetes mellitus (GDM) than the general U.S. population. The purpose of this study was to beta test Stopping GDM (SGDM), a GDM risk reduction intervention for at-risk AIAN teens, before beginning a randomized controlled trial.MethodA sample of 11 AIAN mothers and daughters were recruited through an urban Indian health program. Daughters were at risk of GDM as assessed by a BMI ≥ 85th percentile. Pre- and posttest online questionnaires evaluated the online intervention (e-book and video).ResultsMean pre- to posttest knowledge increased for mothers and daughters on diabetes prevention, reproductive health, and GDM knowledge. Daughters demonstrated an increased self-efficacy for healthy living and pregnancy planning. Satisfaction for the e-book, video, and online survey was moderately high to very high.DiscussionThe SGDM intervention is feasible and acceptable in AIAN mother–daughter dyads. These findings informed the SGDM intervention and the randomized controlled trial evaluation protocol.     

Cardiovascular disease in childhood: the role of obesity

In recent years, childhood obesity is becoming an epidemic health problem. It is now evident from many studies that childhood obesity is correlated with adult excess weight status and the development of risk factors for cardiovascular diseases in adulthood, including hypertension, type 2 diabetes mellitus, dyslipidemia, and metabolic syndrome. The exposure to obesity and to the above risk factors during childhood subsequently lead to atherosclerotic development, such as altered vascular structure and function, although the mechanisms are still unclear. Several non-invasive, and thus easy-to-obtain measures of arterial structure and function, have been shown to be clinically useful in providing information about vasculature early in the course of atherosclerosis, including measurement of endothelial function, carotid intima media thickness, and arterial stiffness. The early detection of cardiovascular abnormalities is essential because the control of the atherogenic process is more effective during its early stages. The present review focuses on the cardiovascular consequences of obesity, on the mechanisms and the methods of measurement of endothelial dysfunction in obese children and adolescents, and on the ways of intervention for the improvement of vascular health.     

Type 2 diabetes,polycystic ovary syndrome and the insulin resistance syndrome in adolescents: Are they one big iceberg?

Obesity in children may cause overt clinical disease in childhood. The complex endocrine and metabolic changes of obesity and insulin resistance in adolescents result in hyperinsulinemia, dyslipidemia, hypertension, steatohepatitis, glucose intolerance, type 2 diabetes, acanthosis nigricans and ovarian hyperandrogenemia, commonly known as polycystic ovarian syndrome (PCOS). Type 2 diabetes and PCOS in adolescents are new endocrine diseases in this age group that require unique approaches to diagnosis and treatment. The direct correlation between duration of disease and control of the disease, and subsequent long term complications of these two diseases, predict serious morbidity in young adult life for the affected adolescents. Pediatricians have an important role in the prevention, diagnosis and treatment of obesity, insulin resistance syndrome, type 2 diabetes and PCOS.