Gestational diabetes: is a higher cesarean section rate inevitable?

OBJECTIVE: To determine the rate of and indication for cesarean section for women with gestational diabetes mellitus (GDM) compared with glucose-tolerant women. RESEARCH DESIGN AND METHODS: From a consecutive series of women with GDM seen over a 9-year period for medical management, women who had had a cesarean section were identified and the reason for the section determined from a review of the medical record. A control group of women who had had a section were obtained from an existing database of glucose-tolerant women. RESULTS: The section rate for women with GDM was higher at 19.8% than the 15.6% for glucose-tolerant women. However, after adjustment for age and parity, no significant differences were found. There were also no differences found for the primary indication for section. CONCLUSIONS: In our health area of New South Wales, Australia, women with GDM do not have a higher section rate compared with glucose-tolerant women. Concerns about the diagnosis of GDM leading to an increased rate of obstetric intervention should not be generalized.     

What degree of maternal metabolic control in women with type 1 diabetes is associated with normal body size and proportions in full-term infants?

OBJECTIVE: To assess what degree of maternal metabolic control in women with type 1 diabetes is associated with normal fetal growth and results in normal neonatal body proportions in a group of full-term infants. RESEARCH DESIGN AND METHODS: We investigated the anthropometric characteristics of 98 full-term singleton infants born to 98 Caucasian women with type 1 diabetes enrolled within 12 weeks of gestation. The type 1 diabetic mother-infant pairs were divided into three groups on the basis of the daily glucose levels reached during the second and third trimesters of pregnancy (group 1: 37 mother-infant pairs with an average daily glucose level during the second and third trimesters of < or =95 mg/dl; group 2: 37 mother-infant pairs with an average daily glucose level during the second trimester of >95 mg/dl and during the third trimester of < or =95 mg/dl; group 3: 24 mother-infant pairs with an average daily glucose level during the second and third trimesters of >95 mg/dl; control group: 1,415 Caucasian mother-infant pairs with full-term singleton pregnancies and normal glucose challenge test screened for gestational diabetes. RESULTS: Infants of diabetic mothers in group 1 were similar to those of the control group in birth weight and in other anthropometric parameters. In contrast, offspring of diabetic mothers of groups 2 and 3 showed an increased incidence of large-for-gestational-age infants, significantly greater means of ponderal index and thoracic circumferences, and significantly smaller cranial/thoracic circumference ratios with respect to the control group. CONCLUSIONS: The results of our study suggest that, in diabetic pregnancies, only overall daily glucose values < or =95 mg/dl throughout the second and third trimesters can avoid alterations in fetal growth.     

Inhaled human insulin: an inspiration for patients with diabetes mellitus?

Inhaled insulin offers a novel option for controlling blood glucose levels in type 1 and type 2 diabetes, obviating the need for multiple daily injections. The first of several delivery systems, insulin Exubera, was recently approved by the US Food and Drug Administration (FDA). However, questions remain regarding its efficacy, cost-effectiveness, and possible deleterious effects on pulmonary function. This review will discuss the pharmacology, efficacy, important clinical trials, and practical aspects of inhaled insulin, and potential concerns associated with its use.     

How effective is a short‐term educational and support intervention for families of an adolescent with type 1 diabetes?

Purpose. To study adaptation and coping strategies of parents who had adolescents with diabetes and the effect of a short‐term educational and support intervention. Design and Method. A quasi‐experimental design was used in the study on 23 families of adolescents with diabetes. Results. A significant difference was found between parents' coping patterns before the intervention. Fathers were, however, found to rate their coping patterns significantly more helpful after the intervention than before. The mothers demonstrated, nevertheless, a significantly greater use of all the coping patterns. Practice Implications. Educational and support intervention is helpful for parents of adolescents with diabetes.     

Are maternal and sonographic factors associated with the detection of a fetal echogenic cardiac focus?

OBJECTIVE: To evaluate the influence of maternal weight and the orientation of the fetal 4-chamber heart view on the detection of a fetal echogenic cardiac focus. METHODS: In this nested case-control study, 103 women undergoing anatomic surveys at 15 to 22 weeks between January 1, 1997, and June 15, 1999, were identified as having an echogenic cardiac focus via our computerized database. A control group was selected from among the same group of patients. Data were collected from the sonography reports, prenatal records, and sonographic images of 4-chamber heart views; maternal characteristics and sonographic details were recorded, including the orientation of the 4-chamber view (apical, basilar, and right and left lateral). RESULTS: Gravidas in the echogenic cardiac focus group were more likely to be of lower weight (68.0 +/- 14.4 versus 72.9 +/- 18.3 kg; P = .04), of lower body mass index (25.5 +/- 5.3 versus 27.3 +/- 6.2 kg/m2; P = .03), of younger age (24.4 +/- 6.5 versus 26.9 +/- 6.9 years; P = .01), and African American or Asian (37.9% versus 27.2% and 9.7% versus 2%; P = .01). Cases were scanned at earlier gestational ages (18.9 +/- 1.6 versus 19.5 +/- 1.7 weeks; P = .01). The focus group was more likely to have had an apical view of the fetal heart taken (80.8% versus 51.4%; P = .0001). Controls were more likely to have had a right lateral view taken (44.6% versus 20.8%; P = .002). No significant difference was found between groups in terms of any other maternal or sonographic variable studied. CONCLUSIONS: The echogenic cardiac focus group was more likely to have a lower body mass index and to be scanned with the apical fetal heart view. The orientation of the fetal 4-chamber heart view exerted the most statistically significant influence on detection rates for the echogenic cardiac focus, implying that the more technically facile the sonographic study, the more likely an echogenic cardiac focus will be found.     

Evaluating the treatment of hypertension in diabetes mellitus: a need for better control?

Objectives To determine how well and to what extent blood pressure (BP) is controlled in diabetic hypertensive patients treated by primary care doctors, and to evaluate drug therapy in the backdrop of risk factors and laboratory findings. Methods A therapeutic audit of the medical records of diabetic hypertensives from nine primary care health centres in Bahrain. Results In 266 diabetic hypertensives (82 males and 184 females), the recommended target BP < 130/< 85 mmHg (WHO/ISH guidelines, 1999) was achieved in 20 (9.8%) with a BP of 119 ± 4/76 ± 5 mmHg. Among those who did not achieve target BP, 70 (34.5%) lacked systolic BP control (BP = 153 ± 17/79 ± 3 mmHg), four (2%) lacked diastolic BP control (BP = 123 ± 3/86 ± 3 mmHg) and 109 (53.7%) lacked both systolic and diastolic BP control (BP = 158 ± 20/94 ± 7 mmHg). The mean age of the group achieving target BP was significantly lower than the group which lacked systolic BP control (51.6 ± 9 vs. 63.5 ± 9 years; P < 0.0001). While there were no significant differences in fasting blood glucose, glycosylated haemoglobin, triglycerides, urea, creatinine, uric acid and serum electrolytes between the group achieving target BP vs. groups without target BP, a significant difference in total cholesterol was seen. Patients with ischaemic heart disease and/or isolated systolic hypertension did not achieve the target BP. Antihypertensive monotherapy was prescribed in 145 (54.5%) patients, whereas two‐ and three‐drug combinations were prescribed in 32.3 and 8.2% of patients, respectively. As monotherapy, angiotensin‐converting enzyme (ACE) inhibitors were the most frequently prescribed drugs followed by β‐blockers, calcium channel blockers (CCBs) and diuretics. As two‐drug combinations, an ACE inhibitor with a β‐blocker/diuretic and a β‐blocker with a CCB/diuretic were usually prescribed. Conclusions According to the WHO/ISH 1999 guidelines, approximately one out of 10 diabetic hypertensives achieved target BP control. In many instances, the drug therapy prescribed was inappropriate considering the comorbidity in patients and their laboratory findings. Improved BP control is needed in treating high‐risk groups such as patients with diabetes mellitus, and efforts should be made to improve the treatment of hypertension in the primary care setting.     

Do obesity and low levels of physical activity increase the risk for developing type 2 diabetes mellitus among women with prior gestational diabetes in rural China?

Moderate-to-vigorous intensity physical activity (MVPA) and obesity play important roles in the development of type 2 diabetes mellitus (T2DM) among women with prior gestational diabetes mellitus (GDM). Yet, how MVPA affects the risk of developing T2DM among women with prior GDM across the different categories of obesity indicators is unclear. This study aimed to describe the levels of postpartum abnormal glucose tolerance (AGT), obesity indicators (body mass index [BMI] and waist circumference [WC]), and MVPA and to explore the independent effect and joint effect of MVPA and obesity indicators (BMI and WC) on the risk for developing AGT among women with prior GDM in rural China. A total of 425 women with prior GDM were recruited from two county-level hospitals in Western and Eastern Hunan, China. Data were collected with self-reported measurements on sociodemographics and clinical factors as well as postpartum weight-related behaviors (physical activity and dietary intake). The 75-g oral glucose tolerance test, weight, height, and WC were measured on site. Binary logistic regression models and multiplitive interaction models were used to explore the independent and joint associations of BMI and MVPA as well as WC and MVPA on AGT, respectively. One-fifth (20.9%) of the sample women had AGT. The obesity indicators were significantly associated with an increased risk of postpartum AGT, but MVPA was not. In joint effect analyses, larger WC and insufficient MVPA were not significantly associated with increased risk of AGT compared with normal WC and sufficient MVPA (mutually adjusted odds ratio [OR], 1.43; 95% confidence interval [CI], 0.46–4.43; p > .05). In joint effect analyses of MVPA and BMI, the mutually adjusted OR for developing AGT in women who were obese and had insufficient MVPA was 4.49 (95% CI, 1.35–14.92; p < .05) compared with normal weight and sufficient MVPA. Adequate weight management and increased MVPA are warranted for Chinese women with prior GDM to prevent T2DM.     

A review of the relationship between depression and diabetes in adults: is there a link?

OBJECTIVE: To review the support for two hypotheses concerning the interrelationship between depression and diabetes and to identify areas in which more research is needed. RESEARCH DESIGN AND METHODS: A review was conducted using primarily electronic databases. Articles relating to diabetes and depressive symptomatology, depressive disorder, and dysthymic disorder were selected. The study focuses mainly on adults with diabetes. RESULTS: The initial onset of major depressive disorder (MDD) seems to be independent of the onset of type 2 diabetes, but results remain equivocal for type 1 diabetes. However, in both type 1 and type 2 diabetes, diabetes-related psychological and physiological processes may be involved in the higher recurrence and longer duration of MDD and depressive symptomatology CONCLUSIONS: The hypotheses that the initial occurrence of clinically significant depression, MDD, results from either biochemical changes directly due to type 2 diabetes or its treatment or from the psychosocial demands imposed by the illness or its treatment do not seem to be supported. MDD in diabetic individuals represents a multidetermined phenomenon resulting from interactions between biologic and psychosocial factors. This interaction may increase the probability of developing type 2 diabetes in otherwise healthy individuals.     

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.     

Increased prevalence of depression and anxiety among subjects with metabolic syndrome and known type 2 diabetes mellitus – a population-based study

Objectives: The metabolic syndrome (MetS) is a cluster of cardiovascular risk factors associated with high cardiovascular morbidity and mortality. The MetS and its elements have been linked to anxiety and depressive disorders. The aim of the current cross-sectional study was to assess the prevalence of depression and anxiety, measured by the Zung Self-Rating Scale in subjects with and without the metabolic syndrome and diabetes.

Methods: A total of 2111 adults were included, 1155 female, age 47.6 (13.7) and 956 male, age 45.2 (13.5). All participants filled questionnaires covering current and past disorders and medication, smoking and family history. Zung self-rating depression and anxiety scales were completed. Body weight, height and waist circumference were measured, BMI was calculated, serum glucose and lipids were measured.

Results: Depression (SDSi) and anxiety scores (SASi) were higher in the females and increased with age (p < 0.001). SDSi was higher in the females and males with metabolic syndrome (MetS) (50.9 ± 9.8 vs. 45.9 ± 8.9, p < 0.001 and 42.7 ± 9.2 vs. 40.5 ± 7.9 p < 0.001, respectively). SASi was higher in the MetS subjects (females 50.59 ± 11.35 vs. 45.97 ± 10.58, p < 0.001; males 40.48 ± 10.1 vs. 38.04 ± 8.42, p < 0.001). Both SDSi and SASi were higher in the subjects with known diabetes than in those with normal glucose tolerance (Mann-Whitney both p < 0,001). Positive depressive scores were more prevalent in subjects with MetS than those without (females 54% vs. 31.6%, p < 0.001; males 22.7% vs. 12.3%, p < 0.001). Depression and anxiety were more prevalent in the subjects with known diabetes than in those with normal glucose tolerance but not in the newly-diagnosed diabetes. The OR for depressiveness was 2.0 (1.3; 2.6) in subjects with MetS and 4.2 (2.3; 7.8) in those with known diabetes.

Conclusions: In conclusion, depressiveness and anxiety were associated positively with age and female gender and were more prevalent among subjects with MetS and known diabetes mellitus.